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Ctriuntbta  (Mntttewttp 

College  of  ^fipfi^ictanig  anb  burgeons; 
Hihxavp 


A  MANUAL 


OP 


Auscultation  and  Percussion; 


EMBRACING  THE 


PHYSICAL  DIAGNOSIS  OF   DISEASES  OF  THE  LUNGS 
AND  HEART,  AND  OF  THORACIC  ANEURISM. 


BY 
AUSTIN  FLINT,  M.D., 

PROFESSOR  OF  THE  PRI^X•IPLES  AND  PRACTICE  OF  MEDICINE  AND  OF 

CLINICAL  MEDICINE  IN  THE  BELLEYUE  HOSPITAL 

MEDICAL  COLLEGE,  ETC.,   ETC. 


THIRD  EDITION,  REVISED. 


PHILADELPHIA: 

HENRY   C.   LEA^S   SON   &   CO. 

1883. 


Entered,  according  to  Act  of  Congress,  in  the  year  1880,  by 

HENRY    C.    LEA, 

In  the  office  of  the  Librarian  of  Congress.     All  rights  reserved. 


SHKUMAN  &  CO.,   riMNTERS. 


PREFACE  TO  THE  THIRD  EDITION. 


In  the  revision  of  this  manual  for  a  third  edition,  it 
has  been  deemed  advisable,  as  in  the  previous  editions, 
to  restrict  its  scope  to  auscultation  and  percussion  con- 
sidered chiefly  with  reference  to  their  practical  applica- 
tion, and  to  present  these  with  as  much  condensation  as 
possible.  In  the  present  edition,  the  modes  by  which 
pulmonary  signs  may  be  reproduced  in  the  lungs  re- 
moved from  the  body,  and  by  artificial  illustrations, 
have  been  briefly  stated.  The  author  has  also  intro- 
duced some  practical  points  kindly  suggested  by  his 
friend  and  colleague,  Professor  Janeway.  The  speedy 
exhaustion  of  the  second  edition  may,  perhaps,  be  fairly 
regarded  as  evidence,  not  alone  of  the  usefulness  of  the 
work  to  the  medical  student  and  practitioner,  but  of  an 
increasing  appreciation  of  the  importance  of  the  study 
of  auscultation  and  percussion,  as  well  as  of  the  analytical 
method  by  which  the  study  is  facilitated,  and  knowledge 
of  the  physical  signs  made  readily  available  in  diag- 
nosis. 

New  York,  March,  1883. 


PREFACE  TO  THE    SECOND  EDITION. 


This  work  contains  the  substance  of  the  lessons  which 
the  author  has  for  many  years  given,  in  connection  with 
practical  instruction  in  auscultation  and  percussion,  to 
private  classes  composed  of  medical  students  and  prac- 
titioners. 

In  his  courses  of  practical  instruction  his  plan  has 
been,  1st.  To  simplify  the  subject  as  much  as  possible, 
avoiding  all  needless  refinements ;  2d.  To  consider  the 
distinctive  characters  of  the  different  physical  signs  as 
determined,  not  by  analogies,  nor  by  deductions  from 
physics,  but  by  analysis,  and  as  based  especially  on 
variations  in  the  intensity,  pitch,  and  quality  of  sounds ; 
3d.  To  impress  the  fact  that  the  significance  of  physical 
signs  relates  to  certain  physical  conditions,  and  the  im- 
portance of  a  familiar  acquaintance  with  these  conditions, 
as  well  as  with  the  distinctive  characters  of  the  signs  by 
which  they  are  represented  ;  4th.  To  enforce  the  neces- 
sity of  sufficient  study  of  the  physical  conditions  and  the 
signs  of  health,  as  a  sine  qua  non  for  success  in  the 
study  of  the  physical  diagnosis  of  diseases;  and,  5th. 
To  waive  discussion  of  the  mechanism  of  signs,  when- 


Vlll  PREFACE    TO    THE    SECOND    EDITION. 

ever  this  is  open  for  discussion,  taking  the  ground  that 
our  knowledge  of  the  significance  of  signs  rests  solely  on 
the  constancy  of  their  connection  with  the  physical  con- 
ditions which  they  represent. 

This  plan,  of  which  the  utility  has  been  confirmed  by 
continued  experience,  has  been  followed  throughout  the 
present  volume,  and  the  favor  with  which  the  work  has 
been  received  has  seemed  to  show  that  no  radical  changes 
were  required.  In  revising  it  for  a  second  edition,  there- 
fore, the  author  has  confined  himself  to  such  additions  as 
seemed  likely  to  render  it  more  useful  not  only  to  stu- 
dents engaged  in  the  practical  study  of  the  subject,  but 
also  to  practitioners  as  a  hand-book  for  ready  reference. 

New  York,  January,  1880. 


CONTENTS. 


CHAPTER   1. 

INTRODUCTION. 

PAGE 

Definition  of  percussion  and  auscultation — The  sounds  obtained 
by  these  methods  representing  healthy  and  morbid  physical  con- 
ditions— Definition  of  signs— The  basis  of  our  knowledge  of 
signs  the  constancy  of  association  of  certain  sounds  with  certain 
physical  conditions  in  health  and  disease — The  present  state  of 
perfection  of  our  knowledge  of  signs  furnished  l)y  auscultation 
and  percussion — Requirements  for  the  successful  study  of  these 
methods  of  exploration — The  anatomy  and  physiology  of  the 
chest — An  enumeration  of  the  points  relating  thereto  which  are 
of  especial  importance — The  physical  conditions  incident  to  the 
different  diseases  of  the  chest ;  the  conditions  relating  to  the  res- 
piratory system  stated,  and  a  summary  of  them — The  distinctive 
charactersof  healthy  and  morbid  signs ;  variations  in  intensity, 
pitch,  and  quality,  considered  as  the  chief  source  of  the  char- 
acters distinguishing  the  signs  of  disease  from  each  other  and 
from  those  of  health — Other  distinctions  than  those  of  intensity, 
pitch,  and  quality — The  analytical  method  of  the  study  of  aus- 
cultation and  percussion — The  significance  of  the  signs  as  re- 
gards the  physical  conditions  which  they  severally  represent —  " 
Morbid  conditions,  not  individual  diseases,  represented  by  the 
morbid  signs — Regional  divisions  of  the  chest — Anatomical  re- 
lations of  the  regions  severally  to  the  parts  within  the  chest,     .      13 


CHAPTER    II. 

PERCUSSION  IN   HEALTH. 

Percussion  with  the  fingers  or  with  a  percussor  and  pleximeter 
— The  normal  vesicular  resonance  on  jiercussion  ;  its  distinctive 
characters  relating  to  intensity',  pitch,  and  quality — Variations 
in  the  characters  of  the  normal  vesicular  resonance  in  different 


CONTENTS. 


PACE 

persons — Relation  of  the  pitch  of  resonance  to  the  vesicular 
quality — Tympanitic  resonance  over  the  abdomen — Variations 
of  the  normal  resonance  in  the  diflferent  regions  of  the  chest 
— Enumeration  of  the  regions  in  which  the  resonance  on  the 
two  sides  varies,  and  those  in  which  it  is  identical  in  health 
— Influence  of  age  on  the  normal  resonance — Influence  of  the 
acts  of  respiration  on  the  resonance — Eules  in  the  practice  of 
percussion, 38 


CHAPTER    III. 

PERCUSSIOX   IN   DISEASE. 

Enumeration  of  the  signs  of  disease  furnished  by  percussion — Re- 
quirements for  practical  knowledge  of  these  signs — The  dis- 
tinctive characters  of,  the  morbid  physical  conditions  repre- 
sented by,  and  the  difierent  diseases  into  the  diagnosis  of  which 
enter,  these  signs,  severally,  to  wit,  1.  Absence  of  resonance  or 
flatness  ;  2.  Diminished  resonance  or  dulness  ;  3.  Tympanitic 
resonance ;  4.  Vesiculo-tympanitic  resonance ;  5.  Amphoric  re- 
sonance; 6.  Cracked-metal  resonance — Sense  of  resistance  felt 
in  the  practice  of  percussion,  as  a  morbid  sign,  ....       54 


CHAPTEE    IV. 

AUSCULTATION   IN  HEALTH. 

Importance  of  the  study  of  the  auscultatory  sounds  in  health — 
Immediate  and  mediate  auscultation — Advantages  of  the  bin- 
aural stethoscope — Rules  to  be  observed  in  auscultation — Di- 
visions of  the  study  of  auscultation  in  health — The  normal 
laryngeal  and  tracheal  respiration — The  normal  vesicular  mur- 
mur ;  its  distinctive  characters,  and  the  variations  in  the  differ- 
ent regions  on  the  same  side,  and  in  corresponding  regions  on 
the  two  sides  of  the  chest — The  normal  vocal  resonance — The 
laryngeal  and  tracheal  voice  and  whisper — The  normal  thoracic 
vocal  resonance  and  fremitus ;  the  distinctive  characters  of 
each  ;  the  variations  in  difierent  regions  on  the  same  side,  and 
in  corresponding  regions  on  the  two  sides  of  the  chest — The 
normal  bronchial  whisper,  with  its  variations  in  different  re- 
gions on  the  same  side,  and  in  corresponding  regions  on  the 
two  sides  of  the  chest, 65 


CONTENTS.  Xi 

CHAPTEK   V. 

AUSCULTATION   IN  DISEASE. 

PAGE 

The  respiratory  signs  of  disease: — Abnormal  modifications  of 
the  normal  respiratory  sounds: — Increased  vesicular  murmur 
— Diminished  vesicular  murmur — Suppressed  respiratory  sound 
— Bronchial  or  tubular  respiration — Broncho-vesicular  respira- 
tion— Cavernous  respiration — Broncho-cavernous  respiration — 
Vesiculo-cavernous  respiration — Amphoric  resinration — Short- 
ened inspiration — Prolonged  expiration — Interrupted  respira- 
tion. Adventitious  respiratory  sounds  or  rales : — Laryngeal  and 
tracheal  rales.  Moist  bronchial  rales,  coarse,  fine,  and  subcrepi- 
tant — Vesicular  or  crepitant  rale — Cavernous  or  gurgling  rale 
— Pleural  friction  rales,  metallic  tinkling  and  splashing.  In- 
determinate rales — The  vocal  signs  of  disease  : — Bronchophony 
— Whispering  bronchophony — ^gopbony — Increased  vocal  re- 
sonance— Increased  bronchial  whisper — Cavernous  whisper — 
Pectoriloquy — Amphoric  voice  or  echo — Diminished  and  sup- 
pressed vocal  resonance — Diminished  and  suppressed  vocal  fre- 
mitus— Metallic  tinkling.  Signs  obtained  by  acts  of  coughing 
or  tussive  signs, 85 

CHAPTEK   VI. 

THE   PHYSICAL   DIAGNOSIS   OF   DISEASES   OF   THE  RESPIRATORY 

ORGANS. 

Affections  of  the  larynx  and  trachea — Bronchitis  seated  in  large 
bronchial  tubes — Bronchitis  seated  in  small  bronchial  tubes,  or 
capillary  bronchitis — Collapse  of  pulmonary  lobules — Lobular 
pneumonia — Asthma — Pulmonary  or  vesicular  emphysema — 
Pleurisy,  acute  and  chronic— Empyema — liydrothorax — Pneu- 
mothorax— Pneumo-hydrothorax — Pneumo-pyothorax — Acute 
lobar  pneumonia — Circumscribed  pneumonia — Embolic  pneu- 
monia— Hsemorrhagic  infarctus — Pulmonary  apoplexy — Pul- 
monary gangrene — Pulmonary  oedema — Carcinoma  of  lung — 
Tumor  within  the  chest — Acute  miliary  tuberculosis — Pulmo- 
nary phthisis — Fibroid  phthisis,  interstitial  pneumonia,  or  cir- 
rhosis of  lung — Diaphragmatic  hernia, 136 


Xll  CONTENTS. 


CHAPTEE   YII. 

THE   PHYSICAL    CONDITIOKS   OF   THE   HEART   IN    HEALTH    AND 
DISEASE.      THE   HEART-SOUNDS  AND  CARDIAC    MURMURS. 

PAGE 

Physical  conditions  of  the  heart  in  health  : — Boundaries  of  the 
prsBcordia — Normal  situation  of  the  apex-beat — Boundaries  of 
the  deep  and  of  the  superficial  cardiac  space — Relations  of  the 
aorta  and  the  pulmonary  artery  to  the  walls  of  the  chest — The 
heart-sounds — Characters  distinguishing  the  first  and  the  second 
sound — Mechanism  of  the  production  of  the  heart-sounds — Aus- 
cultation of  the  pulmonic  and  the  aortic  second  sound  separately 
— Movements  of  the  auricles  and  ventricles  in  relation  to  each 
other.  Physical  conditions  of  the  heart  in  disease  : — Enlarge- 
ment of  the  heart — Hypertrophy  and  dilatation — Abnormal  im- 
pulses of  the  heart,  and  modifications  of  the  apex-beat — Valvu- 
lar lesions — Roughness  of  the  pericardial  surfaces — Liquid 
with  in  the  pericardial  sac — Abnormal  modifications  of  the  heart- 
sounds — Reduplication  of  heart-souuds — Cardiac  murmurs — 
Normal  and  abnormal  blood-currents  within  the  heart,  and 
their  relations  with  the  heart-sounds — Mitral  direct  murmur — 
Mitral  regurgitant  murmur — Mitral  systolic  non-regurgitant, 
or  intra-ventricular  murmur — Aortic  direct  murmur — Aortic 
regurgitant  murmur,  and  an  aortic  diastolic  non-regurgitant 
murmur — Coexisting  endocardial  murmurs — Tricuspid  direct 
murmur — Tricuspid  regurgitant  murmur^Pulmonic  direct 
murmur — Pulmonic  regurgitant  murmur — Facts  of  practical 
importance  in  relation  to  endocardial  murmurs — Pericardial 
.  or  friction  murmur, 181 


CHAPTEE   VIII. 

THE  PHYSICAL   DIAGNOSIS   OF   DISEASES   OF   THE   HEART  AND   OF 
THORACIC  ANEURISM.  U 

Enlargement  of  the  heart  by  hypertrophy  and  dilatation — Val- 
vular lesions,  mitral,  aortic,  tricuspid,  and  pulmonic — Fatty 
degeneration  and  softening  of  the  heart— Endocarditis — Peri- 
carditis— Functional  disorders— Thoracic  aneurism,        .        .    217 


MANUAL 


OF 


AUSCULTATION  AND  PERCUSSION. 


CHAPTER   I. 

INTRODUCTION. 


Definition  of  percnssion  and  auscultation — The  sounds  obtained  by 
these  methods  representing  healtliy  and  morbid  physical  conditions 
— Definition  of  signs — The  basis  of  our  knowledge  of  signs  the  con- 
stancy of  association  of  certain  sounds  with  certain  physical  condi- 
tions in  health  and  disease — The  present  state  of  perfection  of  our 
knowledge  of  signs  furnished  by  auscultation  and  percussion — Ee- 
quirements  for  the  successful  study  of  these  methods  of  exploration 
— The  anatomy  and  physiology  of  the  chest — An  enumeration  of  the 
points  relating  thereto  which  are  of  especial  importance — The  phys- 
ical conditions  incident  to  the  difl'erent  diseases  of  the  chest  :  the 
conditions  relating  to  the  respiratory  system  stated,  and  a  summary 
of  them — The  distinctive  characters  of  healthy  and  morbid  signs; 
variations  in  intensity,  pitch,  and  quality,  considered  as  the  chief 
source  of  the  character  distinguishing  the  signs  of  disease  from  each 
other  and  from  those  of  health — Other  distinctions  than  those  of 
intensity,  pitch,  and  quality — The  analytical  method  of  the  study 
of  auscultation  and  j)ercussion — The  significance  of  signs  as  regards 
the  physical  conditions  which  they  severally  represent — Morbid  con- 
ditions, not  individual  diseases,  represented  by  the  morbid  signs — 
Eegional  divisions  of  the  chest — Anatomical  relations  of  the  regions 
severally  to  the  parts  within  the  chest. 

Physical  Exploration. 

The  physical  exploration  of  the  chest  embraces  six 
different  methods,  namely  :  auscultation,  percussion,  in- 
spection, palpation,  mensuration,  and  succussion.  Of 
these,  auscultation  and  percussion,  dealing  with  sounds, 
involve  the  sense  of  hearing.     In  percussion,  the  sounds 


14  INTRODUCTION. 

are  produced  by  striking  upon  the  walls  of  the  chest ;  in 
auscultation,  they  are  caused  by  acts  of  breathing,  speak- 
ing, and  coughing. 

The  sounds  in  auscultation  and  percussion  are,  1st, 
normal  or  healthy  sounds,  being  produced  when  there  is 
no  disease  of  the  chest;  and,  2d,  abnormal  or  morbid 
sounds,  being  produced  when  the  chest  is  the  seat  of  dis- 
ease. The  sounds,  healthy  and  morbid,  constitute  what 
are  known  as  physical  signs.  Frequently,  for  the  sake 
of  brevity,  the  terms  signs,  without  the  word  physical,  is 
used  to  denote  these  sounds.  Conventionally,  physical 
signs,  or  signs,  are  terms  employed  in  a  sense  of  contra- 
distinction from  the  term  symptoms.  The  signs  are  dis- 
tinguished, of  course,  as  normal  or  healthy,  and  abnormal 
or  morbid. 

The  sounds  which  constitute  signs  represent  certain 
physical  conditions  pertaining  to  the  chest.  The  normal 
or  healthy  signs  represent  physical  conditions  existing 
when  the  organs  are  not  affected  by  disease;  the  abnormal 
or  morbid  signs  represent  physical  conditions  which  are 
deviations  from  those  of  health,  being  incident  to  the 
various  diseases  of  the  chest.  The  physical  conditions 
represented  by  signs  may  be  distinguished  as  normal  or 
healthy,  and  abnormal  or  morbid  conditions. 

The  representation  of  healthy  and  morbid  physical 
conditions  by  certain  healthy  and  morbid  signs  is  estab- 
lished by  having  ascertained  a  constancy  of  association 
of  the  siffus  with  the  conditions.  This  constancv  of  as- 
sociation  is  ascertained  by  observation  or  experience. 
The  sounds  which  are  constantly  obtained  by  percussion 
and  auscultation  in  health  are  thereby  establislied  signs 
of  healthy  conditions,  and  the  sounds  which  are  only 
obtained  in  cases  of  disease  are  therebv  established  siffus 


PHYSICAL    EXPLORATION.  15 

of  m()rl)i(l  conditions.  Our  knowledge  of  certain  sounds 
as  the  signs  of  certain  physical  conditions  can  have  no 
reliable  basis  other  than  the  constancy  of  the  connection 
of  the  former  with  the  latter.  This  constancy  of  connec- 
tion is  determined  by  the  study  of  the  sounds  during  life 
and  examination  of  the  organs  after  death.  The  exist- 
ence of  certain  conditions  is  not  to  be  inferred  from  the 
characters  of  certain  sounds  until  the  connection  of  the 
sounds  with  the  conditions  has  been  ascertained  by  ex- 
perience;  then,  and  then  only,  are  the  sounds  to  be 
reckoned  as  signs  of  these  conditions.  So,  also,  it  is  not 
to  be  inferred  from  certain  physical  conditions  found 
after  death,  that  certain  sounds  must  have  been  produced 
during  life,  until  the  connection  between  the  conditions 
a!id  the  sounds  has  been  ascertained  by  experience.  In 
other  words,  our  knowledge  of  signs  as  representing 
physical  conditions,  can  rest  on  no  other  than  a  purely 
empirical  foundation. 

Our  knowledge  of  the  signs  representing  the  physical 
conditions  in  healtli  and  disease,  thanks  to  the  labors  of 
Laennec  and  of  those  who  have  followed  in  his  footsteps, 
has  been  brought  to  great  perfection.  The  practical  ob- 
ject of  this  knowledge  is  to  determine  by  means  of  aus- 
cultation and  percussion,  together  with  the  other  methods 
of  exploration,  the  existence  of  either  healthy  or  morbid 
physical  conditions,  and  to  discriminate  the  latter  from 
each  other;  that  is  to  say,  the  practical  object  is  diag- 
nosis. The  signs  now  known  to  represent  physical  con- 
ditions, healthy  and  morbid,  taken  in  connection  with 
symptoms  and  pathological  laws,  render,  for  the  most 
part,  the  diagnosis  of  diseases  of  the  chest  easy  and 
positive.  Hence,  it  becomes  the  duty  of  the  medical 
student  and  practitioner  to  give  to  auscultation  and  per- 


16  INTRODUCTION. 

cussion  attention  sufficient,  at  least,  for  their  practical 
application  to  the  diagnosis  of  the  diseases  commonly 
met  with  in  medical  practice ;  and  this  duty  is  the  more 
imperative  because  it  involves  neither  peculiar  difficul- 
ties nor  great  labor.  In  entering  upon  the  undertaking 
it  is  important  to  consider  the  requirements  for  the  suc- 
cessful study  of  this  })rovince  of  practical  medicine. 
These  requirements  relate  to :  1st,,  the  anatomy  and 
physiology  of  the  chest;  2d,  the  morbid  physical  condi- 
tions incident  to  the  different  diseases  of  the  chest;  3d, 
the  distinctive  character  of  healthy  and  morbid  signs, 
and  4th,  the  signiticance  of  the  signs  as  regards  the 
physical  conditions  whicii  they  severally  represent. 

Anatomy  and  Physiology  of  the  Respiratory  Organs. 

The  necessity  of  a  certain  amount  of  knowledge  of  the 
anatomy  and  physiology  of  the  chest,  as  a  requirement 
for  the  study  of  auscultation  and  percussion,  together 
with  the  other  methods  of  physical  exploration,  is  too 
obvious  to  need  any  discussion.  The  physical  condi- 
tions of  health  must  be  known  as  preparatory  for  aj)pre- 
ciating  the  piiysical  conditions  of  disease.  It  would  be 
absurd  to  think  of  studying  the  latter  until  the  former 
are  known.  The  student,  therefore,  who  is  not  acquainted 
with  the  anatomy  and  physiology  of  the  chest,  must  defer 
entering  upon  the  study  of  physical  diagnosis  until  this 
requirement  is  fulfilled.  Familiarity  with  the  morbid 
physical  conditions  is  necessary ;  and  for  the  advanced 
medical  student  or  the  practitioner,  it  is  advisable  to  re- 
fresh the  memory  with  a  reviewal  of  certain  anatomical 
and  physiological  points  before  beginning  the  study  of 
auscultiition  and  percussion.  These  points,  relating  es- 
pecially to  the  physical  conditions  of  health,  cannot  be 


ANATOMY    AND    PHYSIOLOGY    OF    GUEST.  17 

considered  in  this  work.  A  simple  enumeration  of  thcni 
can  only  be  introduced,  the  reader  being  referred  for 
details  to  treatises  on  anatomy  and  physiology. 

Important  anatomical  conditions  relate  to  the  bones 
of  the  chest,  namely,  the  general  conformation  of  the 
thorax;  the  differences  in  respect  of  the  obliquity  of  the 
ribs,  from  above  downward  ;  the  direction  of  the  costal 
cartilages,  the  connection  with  the  sternum,  and  the 
angles  formed  by  the  junction  of  the  ribs  and  cartilages; 
the  differences  in  width  of  the  intercostal  spaces  in  the 
upper,  middle,  and  lower  portions  of  the  anterior,  lateral 
and  posterior  aspects  of  the  thorax,  together  with  the  re- 
lations of  the  scalpula  and  clavicle.  The  relative  thick- 
ness of  the  muscular  covering  of  the  chest  in  different 
situations  is  to  be  considered,  and,  in  women,  the  varying 
size  of  the  mammce.  The  attachments  of  the  diaphragm 
to  the  thoracic  walls,  and  its  relations  to  the  organs  be- 
low, as  well  as  above  it,  are  points  of  importance. 

Important  physiological  conditions  relate  to  the  parts 
-which  the  ribs,  costal  cartilages,  sternum  and  diaphragm 
severally  play  in  the  movements  of  respiration.  The 
differences,  in  respect  of  these  movements,  in  tranquil 
and  in  forced  breathing ;  the  contrast  between  the  two 
sexes,  and  between  early  and  advanced  life  are  points  to 
be  studied.  Other  points  are,  the  frequency  of  the 
respirations  in  health,  and  the  relative  duration,  rapidity, 
and  force  of  the  respiratory  and  the  expiratory  move- 
ments. 

Certain  anatomical  and  physiological  points  pertain 
to  the  organs  within  the  chest.  The  more  important  of 
these,  relating  to  normal  physical  conditions,  are  the  fol- 
lowing :  1st,  as  regards  the  lungs,  the  connections  of  the 
pleura,  and  the  smoothness  of  the   pleural   surfaces   in 


1<S  INTRODUCTION. 

contact  with  each  other  ;  the  relations  of  the  apex  and 
base  of  each  hing  to  the  chest-walls,  and  the  differences 
of  the  two  lungs  in  tliis  respect;  the  relative  spaces 
occupied  respectively  by  the  two  lobes  of  the  left,  and 
the  three  lobes  of  the  right  lung;  the  situation  of  the 
interlobar  fissures  in  either  side  on  the  posterior,  lateral, 
and  anterior  aspects  of  the  chest ;  the  arrangement  of  the 
air-vesicles,  pulmonary  lobules,  and  the  different-sized 
intra-pulmonary  bronchial  tubes  ;  the  expansion  of  the 
air-vesicles,  and  the  movement  of  the  current  of  air  from 
larger  to  smaller  bronchial  tubes  in  the  act  of  inspiration, 
the  vesicles  diminishing  in  size,  and  the  current  of  air 
moving  from  smaller  to  larger  tubes  in  the  act  of  expira- 
tion ;  the  difference  in  respect  of  the  relative  proportion 
of  air  and  solids  at  the  end  of  ins})iration  and  at  the  end 
of  expiration  ;  the  extent  to  which  the  volume  of  the 
lungs  may  be  diminished  by  a  forced  act  of  expiration, 
and  increased  by  a  forced  act  of  inspiration  ;  the  rela- 
tions of  the  apices  to  the  subclavian  arteries,  and  the 
variable  extent  to  which  the  apex  rises  on  either  side 
above  the  clavicle.  2d,  as  regards  the  larynx,  trachea, 
and  the  bronchial  tubes  without  the  lungs,  the  anatomy 
and  physiology  of  the  vocal  chords,  of  the  muscles  con- 
cerned in  the  movements  of  respiration  and  of  phonation, 
with  the  relations  of  each  to  the  recurrent  laryngeal 
nerve,  the  size  of  the  rima  glottidis  in  youth,  after  pu- 
berty, and  relatively  in  the  two  sexes,  the  enlargement 
of  the  rima  in  the  act  of  inspiration,  the  diminution  of 
its  size  in  the  act  of  expiration,  and  the  closer  approxima- 
tion of  the  chords  in  the  act  of  coughino^ ;  the  difference 
in  the  amount  of  areolar  tissue  above  the  vocal  chords  in 
chiklren  and  in  adults;  the  situation  of  the  trachea,  and 
the   point  of  its   bifurcation  ;  the  length,  direction  and 


DISEASES    OF    RESPIRATORY    SYSTEM.  19 

size  of  the  two  primary  bronchi  contrasted  with  each 
other,  and  the  secondary  branches  which  penetrate  the 
lungs.  3d,  as  regards  the  heart,  the  boundaries  of  the 
space  which  it  occupies — that  is,  of  the  precordial  space; 
the  relation  of  the  aorta  and  pulmonic  artery  to  the 
walls  of  the  chest;  the  portions  of  the  pr^ecordial  space 
in  which  the  heart  is  covered  and  uncovered  by  lung; 
the  situations  of  the  auricles  and  ventricles  respectively; 
the  rehitions  of  these  to  each  other,  and  the  arrangements 
of  the  valves;  the  currents  of  blood  through  the  orifices 
within  the  heart,  and  the  relations  of  each  of  these  to 
the  heart-sounds ;  the  rhythmical  succession  of  these 
sounds ;  the  differences  which  distinguish  each  from 
the  other  in  respect  of  loudness,  duration,  tone,  quality, 
extent  of  diffusion,  and  the  situation  in  which  each  has 
its  maximum  of  intensity ;  the  mechanism  of  these  sounds, 
and  the  situation  of  the  apex-beat. 

The  foregoing  are  the  anatomical  and  physiological 
points  which  especially  claim  attention  with  reference  to 
normal  physical  conditions,  j^reparatory  to  entering  on 
the  study  of  abnormal  physical  conditions  represented 
by  the  signs  furnished  by  auscultation  and  percussion 
together  with  the  other  methods  of  physical  exploration. 

The  Physical  Conditions  Incident  to  the  Different  Diseases 
of  the  Respiratory  System, 

The  varied  physical  conditions  incident  to  different 
diseases  must  be  known, 'for  it  is  the  immediate  object  of 
auscultation,  percussion,  and  the  other  methods  of  ex- 
ploration, to  ascertain  either  the  existence  or  the  absence 
of  these  morbid  conditions.  Knowledge  of  all  the  im- 
])()rtant  conditions  which  are  deviations  from  those  of 
health,  and  the  relations  of  each  to  different  diseases,  is, 
therefore,  an  essential  requirement. 


20  INTRODUCTION. 

Deviations  from  the  normal  conformation  of  the  chest 
and  the  various  abnormal  movements  of  respiration,  be- 
long properly  among  the  physical  signs  obtained  by  in- 
spection, palpation,  and  mensuration.  For  the  most  part, 
these  signs  represent  morbid  physical  conditions  within 
the  chest.  Certain  conditions  relate  to  the  presence  of 
liquid,  either  serous,  sero-fibrinous,  or  purulent,  within 
tlie  pleural  sac.  The  quantity  of  liquid  may  be  large 
enough  to  compress  the  lung  into  a  solid  mass,  and  to 
enlarge  the  affected  side,  at  the  same  time  restraining  or 
annulling  the  respiratory  movements  ;  the  chest  on  the 
affected  side,  then,  will  contain  only  lung  solidified  by 
compression,  and  liquid.  In  other  cases  the  quantity  of 
liquid  is  either  small,  moderate,  or  considerable,  the 
lung,  then,  containing  a  lessened  quantity  of  air,  and  its 
volume  diminished  in  proportion  to  the  amount  of  liquid. 
These  morbid  conditions  are  incident  to  simple  pleurisy 
with  effusion,  pyothorax  or  empyema,  and  hydrothorax. 

The  pleural  surfaces,  in  cases  of  pleurisy,  may  be 
more  or  less  covered  with  recent  fibrinous  exudation, 
and,  when  not  separated  by  the  presence  of  liquid,  they 
do  not  move  upon  each  other  smoothly  and  noiselessly. 
The  friction  of  the  opposed  surfaces  is  still  more  pro- 
ductive of  audible  and  sometimes  tactile  signs  after  the 
absorption  of  liquid,  when  the  exudation  has  become 
more  adherent  and  dense  than  when  it  is  recent. 

The  presence  of  air  in  the  pleural  space,  either  alone 
or  with  more  or  less  li(|uid,  in  pneumothorax,  may  com- 
press the  lung  into  a  solid  mass,  also  dilating  the  affected 
side,  and  restraining  or  annulling  its  movements  ;  and 
the  air,  with  or  without  liquid,  when  not  in  sufficient 
quantity  to  produce  these  effects,  may  diminish  more  or 
less  the  volume  of  the  lung  and  the  amount  of  air  in  the 


DISEASES    OF    RESPIRATORY    SYSTEM.  21 

pulmonary  vesicles.  These  morbid  conditions  give  rise 
to  characteristic  physical  signs.  The  perforation  of  lung, 
usually  existing  in  cases  of  pneumothorax,  occasions  ad- 
ditional siorns  which  are  characteristic. 

Solidification  of  lung  is  an  important  physical  condi- 
tion incident  to  several  diseases,  irrespective  of  the  con- 
densation, just  referred  to,  caused  by  the  compression  of 
liquid  or  air  in  the  pleural  sac.  Complete  consolidation 
of  an  entire  lobe,  or  of  two  and  even  three  lobes,  exists 
in  tlie  second  stage  of  lobar  pneumonia.  Certain  physi- 
cal signs  represent  this  condition  of  complete  solidifica- 
tion. The  different  degrees  of  solidification,  namely, 
slight,  moderate,  and  considerable,  occur  during  the  stage 
of  resolution  in  cases  of  pneumonia,  and  these  gradations 
are  severally  represented  by  well-defined  characters  per- 
taining to  physical  signs.  Solidification,  circumscribed, 
forming  nodules  which  vary  in  size  and  number,  situated 
in  the  upper,  lower,  or  middle  portion  of  the  lung,  either 
on  one  side  or  on  both  sides,  exists  in  phthisis,  in  broncho- 
pneumonia and  collapse  of  pulmonary  lobules,  in  hyda- 
tids, in  hajmorrhagic  infarctus  and  embolic  pneumonia, 
in  pulmonary  gangrene,  and  in  carcinoma.  It  exists, 
greater  or  less  in  degree  and  more  or  less  extended,  in 
interstitial  pneumonia.  In  these  different  connections 
the  existence  of  solidification,  its  degree  and  extent,  its 
limitation  to  one  situation  or  its  existence  at  different 
points,  are  determinable  by  means  of  physical  signs. 

A  morbid  condition  the  o{)posite  of  solidification  is 
an  abnormal  accujnulation  of  air  within  the  air-vesicles 
of  the  lungs.  This  is  incident  to  pulmonary  or  vesicular 
emphysema,  involving  a  morbid  dilatation  of  the  air- 
vesicles.  Tiie  permanent  expansion  and  increased  vol- 
ume of  the  upper  lobes  in  some  cases  of  this  disease, 


22  INTRODUCTION. 

occasion  a  characteristic  deformity  of  the  chest,  together 
witli  certain  deviations  from  the  normal  movements  of 
respiration,  which  are  also  characteristic.  This  morbid 
condition  is  represented  by  distinctive  signs  furnished 
by  auscultation  and  percussion.  The  extravasation  of 
air  in  the  connective  tissue,  constituting  interlobular  and 
subpleural  emphysema,  in  like  manner  ^ives  rise  to 
signs  furnished  by  these  methods  of  exploration. 

The  presence  of  a  viscid  exudation  within  the  air- 
vesicles  and  bronchioles,  is  a  morbid  physical  condition 
incident  to  lobular  pneumonia,  especially  in  its  first 
stage,  agglutinating  the  walls  of  the  cells  and  bronchioles 
which  may  be  brought  into  contact  or  close  proximity  at 
the  end  of  the  act  of  expiration.  The  separation  of  the 
walls  thus  agglutinated,  in  the  act  of  inspiration,  gives 
rise  to  an  auscultatory  sign  (the  crepitant  rale)  which  is 
pathognomonic  of  that  disease. 

An  accumulation  of  serum  within  the  air-vesicles  con- 
stitutes the  condition  called  pulmonary  oedema.  This 
condition  gives  rise  to  signs  furnished  by  auscultation 
and  percussion. 

I^iquid  within  the  bronchial  tubes  (serum,  pus,  blood, 
or  thin  mucus)  is  a  condition  incident  to  pulmonary 
oedema,  abscess  either  of  the  lung  or  situated  elsewhere 
and  evacuating  through  the  bronchial  tubes,  phthisis, 
bronchorrhagia,pneumorrhagia,  bronchorrhoea,  and  bron- 
chitis. The  passage  of  air  through  the  different  varie- 
ties of  liquid  in  the  tubes  causes  bubbling  sounds  which 
are  ap})reciable  in  auscultation.  The  apparent  size  of 
the  bubbles  (coarseness  or  fineness)  denotes  the  size  of 
the  tubes  in  which  they  are  produced,  and  the  pitch  of 
the  bubbling  sounds  denotes  either  solidification  or  other- 
wise of  the  pulmonary  substance  surrounding  the  tubes 


DISEASES    OF    RESPIRATORY    SYSTExM.  23 

in  which  the  bubbles  are  produced.  Bubbling  sounds 
more  intense  and  on  a  larger  scale  are  caused  by  the 
presence  of  liquid  within  the  trachea  and  larynx,  known 
as  the  tracheal  rales  or  the  death  rattle. 

Diminished  calibre  of  the  bronchial  tubes  within  the 
lungs,  either  localized  or  diffused,  is  a  condition  due  to 
the  presence  of  tenacious  mucus,  and  the  swelling  of  the 
mucous  membrane  in  cases  of  bronchitis.     In  cases  of 
so-called  capillary  bronchitis  the  condition  may  involve 
an  alarmino;  decree  of  obstruction.  The  same  morbid  con- 
dition  is  incident  to  bronchial  spasm  in  asthma,  occasion- 
ing; in  this  disease  g-reat  suffering;,  but  without  immediate 
danger.     The  condition  is  represented  by  auscultatory 
sig-ns  which  enable  the  auscultator  to  differentiate  the 
obstruction  due  to  capillary  bronchitis  from  that  due  to 
bronchial  spasm.    Permanent  obliteration  of  more  or  less 
of  the  bronchial  tubes  is  an  occasional  morbid  condition. 
Obstruction  of  a  bronchial  tube,  either  within  or  with- 
out the  lung,  is  a  morbid  condition  involving  the  loss  of 
respiratory    sound    within    the   area    of  the   bronchial 
branches  and  vesicles  not  receiving  air  in  consequence 
of  the  obstruction.     The  obstruction  may  be  temporary, 
being  caused  by  a  plug  of  mucus  of  sufficient  size  to  pre- 
vent the  passage  of  air  ;  the  morbid  condidon  is  then 
incident  to  bronchitis.    One  of  the  primary  bronchi  may 
be  obstructed  temporarily  by  a  plug  of  mucus;  and  ob- 
struction of  the  larynx  in  childhood  thus  produced  may 
be  sufficient  to  cause  death  by  suffocation.     The  inhala- 
tion of  foreign  bodies  is  another  cause  of  obstruction 
within    the    larynx,  trachea,    or    bronchi.     A  primary 
bronchus  or  the  trachea  may  be  pressed  upon  by  an  aneu- 
rismal  or  other  tumor,  and,  in  this  way,  more  or  less  ob- 
struction to  the  passage  of  air  is  produced.   However  pro- 


24  INTRODUCTION. 

duced,  the  situation  of  the  obstruction  and  its  degree  are, 
in  general,  determinable  by  means  of  auscultatory  signs. 

Dilatation  of  bronchial  tubes  occasions  two  morbid 
physical  conditions  differing  as  regards  their  auscultatory 
signs,  namely,  1st,  an  enlargement  of  greater  or  less  ex- 
tent, the  tubes  preserving  their  cylindrical  form  ;  and 
2d,  a  sacculated  enlargement.  The  former  occurs  gen- 
erally in  connection  with  solidification  around  the  tubes 
from  hyperplasia  of  the  areolar  tissue,  and  is  thus  inci- 
dent to  interstitial  pneumonia.  The  latter  may  give  rise 
to  signs  which  represent  pulmonary  cavities. 

Sacculated  dilatations  of  bronchial  tubes,  and  the  cavi- 
ties incident  to  phthisis,  })ulmonary  abscess,  and  circum- 
scribed gangrene  of  lung,  are  represented  by  well-marked 
and  highly  distinctive  signs  furnished  by  auscultation 
and  percussion.  The  signs  denote  either  that  cavities 
have  flaccid  walls,  which  collapse  in  expiration  and  ex- 
pand in  ins})iration,  or  that,  owing  to  solidification  of 
lung,  they  remain  open  during  both  acts  of  respiration. 

More  or  less  of  the  space  within  the  chest  which,  nor- 
mally, is  occupied  by  lung,  may  be  encroached  upon  by 
aneurisms  or  other  intra-thoracic  tumors.  This  is  a  phy- 
sical condition  giving  rise  to  notably  morbid  signs  fur- 
nished by  auscultation  and  percussion. 

Finally,  an  extremely  rare  morbid  physical  condition 
is  the  presence  of  more  or  less  of  the  hollow  viscera  of 
the  abdomen  within  the  chest,  in  consequence  of  either  a 
congenital  deficiency  in  the  diaphragm,  or  a  wound  pene- 
trating this  muscle  (diaphragmatic  hernia). 

The  foregoing  morbid  physical  conditions  relate  to 
the  respiratory  organs.  Those  relating  to  the  heart  are  de- 
ferred in  order  that  they  may  precede  more  immediately 


DISEASES    OF    RESPIRATORY    SYSTEM.  25 

an  account  of  the  signs  of  cardiac  disease.  As  a  re- 
quirement for  the  study  of  morbid  physical  signs,  the 
foregoing  morbid  physical  conditions  must  be  understood 
and  memorized.  To  assist  the  student  in  the  latter,  a 
summary  of  these  conditions  is  appended. 

Summary  of  Morbid  Physical  Conditions  Incident  to 
Diseases  of  the  Respiratory  Organs. 

1.  An  accumulation  of  liquid,  serous,  sero-fibrinous,  or 
purulent,  sufficient  to  fill  the  affected  side  of  the  chest,  and 
sometimes  causing  more  or  less  enlargemeut. 

2.  Au  accumulation  of  liquid  partially  filling  the  affected 
side  of  the  chest,  the  quantity  being  either  small,  moderate, 
or  considerable. 

3.  Fibrinous  exudation  on  the  pleural  surface. 

4.  Air  with  liquid  within  the  pleural  cavity,  and  perfora- 
tion of  lung. 

5.  Air  without  liquid  in  the  pleural  cavity. 

6.  Solidification  of  lung,  either  complete  or  approximat- 
ing to  completeness. 

7.  Solidification  of  lung,  slight  or  moderate  in  degree. 

8.  Dilatation  of  the  air-vesicles,  involving  within  them 
an  abnormal  accumulation  of  air. 

9.  Extravasation  of  air  Avithin  the  pulmonary  connective 
structure. 

10.  Exudation  within  air-vesicles  and  bronchioles. 

11.  Liquid  in  the  air-vesicles. 

12.  Liquid  (mucus,  serum,  pus,  or  blood)  within  bronchial 
tubes  of  large,  medium,  or  small  size. 

13.  Liquid  within  bronchial  tubes  of  minute  size. 

14.  Obstruction  of  the  pulmonary  bronchial  tubes  by 
mucus,  swelling  of  the  mucous  membrane,  and  spasm  of  the 
bronchial  muscular  fibres. 

15.  Obstruction  of  larynx,  trachea,  or  bronchi  exterior 
to  the  lungs,  by  plugs  of  mucus  or  foreign  bodies. 


26  INTRODUCTION. 

16.  Obstruction  of  the  trachea  or  a  primary  bronchus  by 
aneurismal  or  other  tumors. 

17.  Dilatation  of  bronchial  tubes,  cylindrical  or  saccu- 
lated. 

18.  Pulmonary  cavities. 

19.  Tumor  within  the  chest. 

20.  Diaphragmatic  hernia. 

The  Distinctive  Characters  of  Healthy  and  Morbid  Signs. 

For  the  practice  of  auscultation  and  percussion,  it  is 
essential  to  be  able  to  recognize  the  signs,  severally, 
which  represent  the  different  physical  conditions  in 
health  and  disease.  It  is  essential  to  distinguish  the 
morbid  from  the  healthy  signs,  and  to  discriminate  from 
each  other,  severally,  the  signs  of  disease.  This  recogni- 
tion and  discrimination  of  signs  require  a  knowledge  of 
the  distinctive  characters  belono;ino;  to  each  of  them.  In 
entering  upon  the  study  of  the  signs,  therefore,  it  is  a 
necessary  requirement  to  know  whence  their  distinctive 
characters  are  derived.  To  this  point  of  inquiry  the 
attention  of  the  student  is  now  invited. 

The  signs  being  sounds,  they  are  to  be  recognized  and 
discriminated  in  the  way  in  which  we  practically  recog- 
nize and  discriminate  other  sounds.  It  is  not  necessary, 
in  order  to  do  this,  to  study  the  science  of  acoustics. 
In  becoming  familiar  with  other  sounds,  for  example 
musical  notes  produced  by  different  instruments,  or  the 
varieties  of  the  human  voice,  we  do  not  have  recourse  to 
that  science.  It  suffices  for  all  practical  purposes  to 
contrast  the  sounds  obtained  by  auscultation  and  per- 
cussion with  reference  to  very  simj)le  and  obvious  dif- 
ferences;  and,  yet,  it  is  necessary  to  understand  very 
clearly  in  what  these    differences  consist,  or,  in  other 


HEALTHY    AND    MORBID    SIGNS.  27 

words,  the  sources  of  the  distinctive  characters  of  these 
sounds.  The  more  important  of  the  differences  between 
the  sounds  obtained  by  auscultation  and  percussion  re- 
late to  intensity,  pitch,  and  quality.  The  distinctive 
characters  of  most  of  the  signs  are  derived  from  these 
three  sources.  In  becoming  practically  acquainted  with 
the  signs,  they  are  to  be  contrasted  as  regards  intensity, 
pitch,  and  quality,  precisely  as  we  would  bring  other 
sounds  into  contrast  in  these  three  aspects.  The  dis- 
tinctive characters  of  the  signs,  severally,  are  especially 
derived  from  their  differences  in  these  respects.  The 
distinctions  expressed  by  the  terms  intensity,  pitch,  and 
quality,  are,  therefore,  to  be  made  clear. 

Differences  in  the  intensity  of  sounds  are  easily  under- 
stood. One  sound  is  more  intense  than  another  sound 
when  it  is  simply  louder,  and  varying  degrees  of  inten- 
sity are  expressed  by  such  terms  as  feeble  or  weak  and 
loud,  to  which  may  be  prefixed  adjectives  of  quantity, 
such  as  very,  moderate,  etc.  This  is  ail  that  need  be 
said  with  reference  to  the  first  of  the  three  aspects  under 
which  sounds  are  contrasted.  It  will  be  seen  hereafter 
that  intensity  is  an  essential  element  in  the  distinctive 
characters  of  certain  of  the  signs. 

Differences  in  the  pitch  of  sounds  are  easily  under- 
stood by  those  who  have  given  any  attention  to  music. 
The  differences  are  expressed  by  the  terms  high  and 
low,  to  which  may  be  prefixed  words  denoting  a  greater 
or  less  degree  of  highness  or  lowness.  A  nice  appreci- 
ation of  variations  in  the  pitch  of  musical  notes,  requires 
what  is  known  as  a  "musical  ear;''  but  a  very  nice 
appreciation  is  not  essential  in  comparing,  as  regards 
pitch,  the  sounds  studied  in  auscultation  and  percussion. 
For  the  most  part,  these  sounds  are  not  musical  notes ; 


28  INTRODUCTION. 

nevertheless,  differences  in  pitch  are  readily  perceived. 
A  musical  ear  is  undoubtedly  an  advantage  in  readily 
distinguishing  differences  in  pitch  ;  but  it  is  by  no  means 
a  sine  qua  non.  For  those  who  have  given  no  attention 
to  music,  some  difficulty  may  be  at  first  experienced  in 
judging  correctly  of  differences  in  this  regard ;  but  the 
difficulty  disappears  after  a  little  practice.  Differences 
in  pitch  now  enter  pretty  largely  into  the  distincive 
characters  of  physical  signs  ;  but  by  Laennec,  and  those 
who  immediately  followed  him,  comparatively  little  at- 
tention was  paid  to  the  study  of  sigus  with  reference  to 
these  differences.  The  writer  was  led  to  engage  in  this 
study  a  quarter  of  a  century  ago,  and  hereafter,  in  giv- 
ing an  account  of  the  different  signs,  he  will  claim  to 
have  been  the  first  to  have  clearly  indicated  certain  char- 
acters from  this  source.^ 

Differences  relating  to  quality  are  apt,  at  first,  to  be 
confounded  with  those  relating  to  pitch  ;  hence  the  dis- 
tinction between  pitch  and  quality  must  be  clearly  under- 
stood. We  may  say  of  the  quality  of  a  sound,  that  it 
embraces  whatever  is  not  embraced  in  the  terms  intensity 
and  pitch.  This  is  true  as  a  general  statement.  The 
sense  of  the  term  quality,  in  distinction  from  intensity 
and  pitch,  may  be  most  readily  made  clear  by  an  illus- 
tration. Let  it  be  supposed  that  we  hear  the  notes  of  an 
instrument  which  is  unseen — the  performer,  for  example, 
being  in  another  room.  We  recognize  at  once  the  in- 
strument by  the  notes,  provided  it  be  one  with  which 
we  arc  familiar,  such  as  a  violin,  a  flute,  a  clarionet,  etc. 
We  do  not  need  to  see  the  instrument;  we  recognize  it 

'  Vide  Prize  Essay  on  "Yiiriations  of  Pitch  in  Percussion  and 
Respiratory  Sounds,  and  their  Api)lication  to  Piiysicul  Diagnosis." 
Transactions  of  tlie  American  Medical  Association,  1852. 


HEALTHY    AND    MORBID    SIGNS.  29 

by  the  sounds.  Now,  how  do  we  recognize  it?  Cer- 
tainly not  by  the  intensity  of  the  sounds;  it  matters  not 
whether  these  be  loud  or  weak,  so  that  we  hear  them. 
Certainly  not  by  the  pitch;  for  if  a  piece  of  music  be 
performed,  we  get  both  high  and  low  notes.  We  recog- 
nize the  instrument  by  the  quality  of  the  sounds.  Each 
musical  instrument,  owing  to  its  peculiarity  of  construc- 
tion, yields  sounds  which  are  peculiar  to  it;  and  after 
we  have  become  familiar  with  the  quality  of  sounds 
peculiar  to  an  instrument,  we  immediately  thereby  rec- 
ognize it.  Precisely  in  the  same  way  we  may  recognize 
certain  sounds  produced  by  auscultation  and  percussion 
in  health  and  disease.  The  signs  differ  in  quality  ac- 
cording to  the  physical  conditions  which  they  severally 
represent ;  and  differences  in  quality  will  be  found  here- 
after to  constitute  essential  and  obvious  distinctions  by 
which  the  signs  of  health  and  disease  are  recognized  and 
discriminated.  This  is  a  source  of  some  of  the  most  dis- 
tinctive of  the  characters  of  certain  of  the  physical  signs. 
Of  the  peculiar  quality  of  any  particular  sound  one 
can  form  no  definite  idea  otlierwise  than  by  direct  obser- 
vation. That  is  to  say,  no  one  could  describe  to  another 
the  peculiar  quality  of  a  particular  sound  so  that  it  would 
be  clearly  apprehended  without  the  sound  having  been 
heard.  Imagine  the  attempt  to  describe  the  sound  of  a 
violin  to  a  person  who  had  never  listened  to  the  notes 
from  that  instrument — it  would  be  impossible  to  give  a 
correct  idea  of  it  in  language.  The  only  way  in  which 
an  approximative  idea  could  be  conveyed  in  words,  would 
be  by  comparing  the  quality  to  that  of  some  other  in- 
strument to  the  notes  of  which  there  was  some  resem- 
blance— that  is,  by  analogy.  To  atteinpt  to  describe  the 
quality  of  sounds  to  one  who  had  never  heard  them, 

3 


30  INTRODUCTION. 

would  be  like  describing  colors  to  one  blind.  It  will  be 
seen  hereafter  tliat  the  quality  of  certain  sounds  obtained 
by  auscultation  and  percussion  is  peculiar  to  them,  and 
their  distinctive  characters  in  this  respect  can  be  known 
only  by  direct  observation  ;  they  cannot  be  learned  by 
means  of  any  verbal  description,  nor  by  any  comparisons 
— that  is,  by  analogy. 

Appreciable  variations  in  the  quality  of  sounds  are 
infinite.  This  may  be  illustrated  by  the  human  voice. 
Almost  every  person  may  be  recognized  from  a  peculiar 
quality  of  the  voice  by  one  who  is  familar  with  it;  and 
the  voices  of  thousands  of  persons,  if  compared,  would 
present  shades  of  difference — in  fact,  as  is  well  known, 
it  is  extremely  rare  for  the  voices  of  any  two  persons  to 
be  so  nearly  identical  in  quality  that  they  cannot  be  dis- 
tinguished from  each  other.  As  the  diversities  in  quality 
of  different  sounds  cannot  be  described,  so  they  can  only 
be  designated  by  names  which  are  significant  from  cer- 
tain resemblances.  Terms  based  on  analogies  which  are 
used  to  denote  qualities  of  the  sounds  furnished  by  aus- 
cultation and  percussion  are  the  following:  rough,  harsh 
and  rude,  soft,  blowing,  hollow,  musical,  moist,  dry, 
bubbling,  gurgling,  crackling,  clicking,  rubbing,  grating, 
creaking,  tubular,  cracked  metal,  sibilant  or  whistling, 
sonorous  or  snoring.  All  these  names  owe  their  signifi- 
cance to  resemblances  to  other  sounds.  One  sound  fur- 
nished both  by  auscultation  and  percussion  has  a  quality 
which  is  sui  generis^  and  the  term  used  to  distinguish  it 
is  derived  from  its  source,  namely,  the  vesicular  reso- 
nance, and  the  vesicular  murmur  of  respiration. 

In  addition  to  intensity,  pitch,  and  quality,  as  sources 
of  the  distinctive  characters  of  the  signs  furnished  by 


HEALTHY    AND    MORBID    SIGNS.  31 

auscultation  and  percussion,  there  are  some  other  points 
of  difference;  namely,  the  duration  of  certain  sounds, 
tlieir  continuousness  or  otherwise,  their  apparent  near- 
ness to,  or  distance  from,  the  ear,  their  rhythmical  suc- 
cession, and  their  strong  resemblance  to  particular  sounds, 
such  as  the  bleating  of  the  goat,  the  chirping  of  birds,  etc. 
These  points  of  difference  are  of  lesser  importance,  the 
more  important  relating  to  intensity,  pitch,  and  quality. 

The  study  of  the  different  sounds  furnished  by  auscul- 
tation and  percussion,  with  reference  to  distinctive  char- 
acters relating  especially  to  intensity,  pitch,  and  quality, 
distinct  signs  being  determined  from  points  of  difference 
as  regards  these  characters,  may  be  distinguished  as  the 
analytical  method.  It  may  be  so  distinguished  in  con- 
trast with  the  determination  of  signs  by  deductively 
taking  as  a  standpoint  either  the  physical  conditions  inci- 
dent to  diseases  or  the  sounds.  If  we  undertake  to  decide, 
a  jyriori,  that  certain  sounds  must  be  produced  by  auscul- 
tation and  percussion  when  certain  conditions  are  present, 
we  shall  be  led  into  error;  and  so,  equally,  if  we  under- 
take to  conclude  from  the  nature  of  the  sounds  that  they 
must  represent  certain  conditions.  The  only  reliable 
method  is  to  analyze  the  sounds  with  reference  to  differ- 
ences relating  especially  to  intensity,  pitch,  and  quality, 
and  to  determine  different  signs  by  these  differences,  the 
import  of  each  of  the  signs  being  then  established  by  the 
constancy  of  association  with  physical  conditions.  It  is 
by  this  analytical  method  only  that  the  distinctive  char- 
acters of  signs  can  be  accurately  and  clearly  ascertained. 
This  is  to  be  borne  in  mind  by  the  student  in  physical 
exploration.  He  is  to  become  acquainted  with  the  differ- 
ent signs,  and  to  recognize  them  in  practice,  by  acquiring 


32  INTRODUCTION. 

a  knowledge  of  the  distinctive  characters  of  each,  as  de- 
rived mainly  from  differences  relating  to  intensity,  pitch, 
and  quality.  The  individuality  of  the  signs,  severally, 
can  rest  on  no  other  solid  basis. 

The  Significance  of  the  Signs  as  regards  the  Physical 
Conditions  which  they  severally  represent. 

Knowledge  of  the  significance  of  the  physical  signs  is 
the  complemental  requirement  in  the  study  of  ausculta- 
tion and  percussion.  For  the  successful  employment  of 
these  methods,  in  addition  to  the  recognition  of  each  sign 
by  its  distinctive  characters,  must  be  known  its  sig- 
nificance, that  is,  the  physical  condition  which  it  repre- 
sents. In  this  respect  the  signs  may  be  compared  to  the 
substantives  in  language,  each  having  a  definite  mean- 
ing. The  signs  furnished  by  these  methods  may  be  said 
to  constitute  a  language  with  a  very  small  vocabulary  ; 
or,  taking  as  the  stand{)oint  the  things  signified,  the  dif- 
ferent physical  conditions  manifest  or  express  themselves 
by  means  of  the  signs. 

It  is  to  be  noted  that  the  significance  of  the  morbid 
signs  relates  immediately,  not  to  diseases,  but  to  the 
physical  conditions  incident  thereto.  Very  few  signs  are 
directly  diagnostic  of  any  particular  disease.  They 
represent  conditions  not  peculiar  to  one,  but  common  to 
several,  diseases.  Thus,  solidification  of  lung  exists  in 
pneumonia,  phthisis,  pleurisy  with  effusion,  collapse,  and 
pulmonary  cancer ;  now,  certain  signs  tell  us  that  this 
morbid  condition  exists,  together  with  its  situation,  its 
degree,  and  its  extent.  With  this  information  the  diag- 
nosis of  the  disease  is  made  by  connecting  with  it  patho- 
logical laws,  together  with  the  history  and  symptoms. 
The  student  in  physical  exploration  should  by  no  means 


REGIONAL    DIVISIONS    OF    THE    GUEST.  33 

imagine  that,  for  the  diagnosis  of  diseases,  exclusive  re- 
liance is  to  be  placed  on  the  signs;  they  are  always  to 
be  taken  in  connection  with  pathological  laws,  the  his- 
tory, and  the  symptoms.  Disconnected  from  these,  the 
signs  would  often  lead  to  error,  and  it  is  no  disparage- 
ment to  physical  diagnosis  that  its  reliability  depends 
on  other  facts  than  those  which  belong  exclusively  to  it. 
To  repeat  a  statement  already  made  more  than  once, 
the  significance  of  the  signs,  as  regards  the  conditions 
which  they  severally  represent,  is  based  on  the  constancy 
of  their  association  with  the  latter,  our  knowledge  of 
this  association  being  derived  from  examinations  during 
life  and  after  death. 

Eegional  Divisions  of  the  Chest. 

Before  entering  on  the  study  of  physical  exploration, 
the  student  should  become  acquainted  with  the  divisions 
of  the  surfaces  of  the  anterior,  posterior,  and  lateral 
aspects  of  the  chest  into  circumscribed  spaces  which  are 
called  regions.  These  divisions,  deriving  their  bounda- 
ries and  names  from  their  anatomical  relations,  are  suffi- 
ciently simple. 

Anteriorly  the  chest  is  divided  into  regions  as  follows: 
The  supra  or  post-clavicular  region  extends  from  the 
clavicle  upward  a  short  distance,  corresponding  to  the 
variable  height  to  which  the  lung  rises  above  this  bone. 
The  clavicular  region  embraces  the  space  occupied  by 
the  clavicle.  The  infra-clavicular  reg^ion  embraces  the 
space  between  the  clavicle  and  the  third  rib.  The  mam- 
mary region  is  bounded  above  by  the  third  and  below 
by  the  sixth  rib,  and  the  infra-mammary  region  is  the 
portion  of  the  chest  below  the  sixth  rib. 

Posteriorly  the  divisions  are  Into  the   scapular,  the 


34  INTRODUCTION. 

infra-scapular,  and  inter-scapular  regions.  The  scapular 
region  is  the  space  occupied  by  the  scapula,  and  is  divi- 
ded by  the  spinous  ridge  into  the  upper  and  lower  scapu- 
lar space.  The  infra-scapular  region  is  the  portion 
below  a  horizontal  line  at  the  lower  angle  of  the  scapula. 
The  inter- scapular  region  is  the  space  between  the  pos- 
terior margin  of  the  scapula  and  the  spinal  column. 

Laterally  there  are  two  regions,  namely,  the  axillary 
and  the  infra-axillary.  The  axillary  region  is  the  space 
above  a  horizontal  line  extending  from  the  lower  border 
of  the  mammary  region,  i.  e.,  the  sixth  rib.  The  infra- 
axillary  region  is  the  portion  below  the  axillary  region. 

The  portion  of  the  anterior  surface  occupied  by  the 
sternum  is  divided  into  the  upper  and  the  lower  sternal 
region,  the  space  above  the  sternal  notch  being  the 
supra-sternal  region. 

In  order  to  become  familiar  with  the  foregoing 
regional  divisions,  it  is  recommended  to  the  student  to 
delineate  them  with  ink  on  the  chest  of  the  living  sub- 
ject or  a  cadaver. 

It  is  advisable  to  study  sections,  extending  from  the 
surface  to  the  centre  of  the  chest,  corresponding  to  the 
different  regions,  so  as  to  become  familiar  with  the  rela- 
tion of  each  section  to  the  parts  contained  within  it.  An 
enumeration  of  the  more  important  of  the  anatomical 
relations  of  the  different  regions  is  as  follows : 

1.  Supra- Clavicular  Region. — This  is  relative  to  the 
upper  extremity  or  apex  of  the  lung,  which  rises  above 
the  clavicle  in  different  persons  from  half  an  inch  to  an 
inch  and  a  half.  The  height  is  generally  greater  on  one 
side,  and  this  side  is  usually  the  left. 

2.  Clavicular  Region. — A  small  portion  of  the  lung 


REGIONAL    DIVISIONS    OF    THE    CIIEST.  35 

at  or  near  the  apex  is  contained  in  the  section  corre- 
sponding to  this  region. 

3.  Infra- Clavicular  Region. — The  parts  situated  iierc, 
exclusive  of  the  upper  sternal  region  [vide  No.  7),  are 
the  upper  portion  oflhe  lung,  and  the  extra-pulmonary 
bronchi.  The  differences  between  the  two  primary 
bronchi,  as  regards  direction,  size,  and  length,  are  im- 
portant points  in  the  st#ly  of  this  section. 

4.  Mammary  Region. — The  differences  between  the 
two  sides  in  the  sections  corresponding  to  this  region 
are  important.  These  differences  relate  especially  to  the 
prsecordia,  and  are  involved  in  the  physical  diagnosis 
of  enlargement  of  the  heart.  The  commencement  of 
the  interlobular  fissures  are  in  this  region.  On  the  left 
side  the  fissure  is  between  the  fourth  and  fifth  ribs. 
On  the  right  side  the  fissure  between  the  upper  and 
middle  lobes  begins  at  the  fourth  costal  cartilage,  and 
between  the  middle  and  lower  lobes  a  short  distance 
below.  The  situations  of  the  fissures,  however,  differ 
considerably  during  the  acts  of  inspiration  and  expi- 
ration. 

5.  Infra-mammary  Region, — This  region  differs  in  its 
anatomical  relations  considerably  on  the  two  sides  of  the 
chest.  On  the  right  side  the  liver  pushes  upward  the 
diaphragm  nearly  or  quite  to  the  upper  boundary, 
namely,  the  sixth  rib.  On  the  left  side  the  section  cor- 
responding to  the  region  embraces,  together^ with  the 
anterior  portion  of  the  lower  lobe  of  the  lung,  portions 
of  the  stomach,  spleen,  and  the  left  lobe  of  the  liver. 
The  variable  volume  of  the  stomach  at  different  times 
occasions  considerable  variations  in  the  relative  spaces 
occupied  by  these  different  parts. 


36  INTRODUCTION. 

6.  Supr^a-sterrial  Region. — This  region  is  in  relation 
to  the  trachea. 

7.  Tlie  Upper  Sternal  Region. —  The  bifurcation  of 
the  trachea  is  beneath  the  sternum  at  the  centre  of  a  line 
connecting  the  second  ribs.  Below  this  line  the  lungs 
on  the  two  sides  are  nearly  in  contact  at  the  mesial  line, 
covering  the  primary  bronchi. 

8.  Lower  Sternal  Region. — The  sternum  in  this  re- 
gion covers  a  large  portion  of  the  right  and  a  little  of 
the  left  ventricle. 

9.  Scapular  Region. — The  sections  corresponding  to 
this  region  contains  the  posterior  portion  of  the  uj)per 
lobe  and  a  portion  of  the  upper  part  of  the  lower  lobe  of 
the  lung.  At  the  upper  part  of  the  lower  scapular 
space,  terminates  the  fissure  separating  the  npper  and 
the  lower  lobe.  The  line  of  this  fissure  pursues  an 
oblique  course  to  the  fourth  or  fifth  rib  on  the  anterior 
aspect  of  the  chest. 

10.  Infra-scapular  Region  — On  the  right  side  the 
lung  extends  from  the  upper  boundary  of  this  region  to 
the  eleventh  rib,  the  liver  rising  to  the  latter  point.  On 
the  left  side  the  section  contains  a  portion  of  the  spleen. 

11.  Inter -scapular  Region. — The  trachea  extends  in 
this  section  to  the  fourth  dorsal  vertebra,  where  it  bifur- 
cates. Below  this  point,  on  the  two  sides,  are  situated 
the  primary  bronchi. 

12.  Axillary  Region. — The  section  corresponding  to 
this  region  contains  a  portion  of  tiie  upper  lobe  with 
large  bronchial  tubes. 

13.  Infra-axillary  Region. — This  is  in  relation  to  the 
upper  part  of  the  liver  on  the  right  side,  and  on  the  left 
side  to  a  j)ortion  of  the  spleen  and  stomach,  the  remainder 
of  the  section  occupied  by  lung. 


REGIONAL    DIVISIONS    OF    THE    CHEST.  37 

It  is  recommended  to  the  student  to  become  familiar 
with  the  sections  corresponding  to  the  different  regions, 
by  dissections  for  this  purpose,  and  the  study  of  anatom- 
ical illustrations. 

Askino'  the  student's  careful  attention  to  the  intro- 
ductory  considerations  which  have  been  presented,  aus- 
cultation and  percussion  in  health  and  disease,  and  the 
physical  signs  involved  in  the  diagnosis  of  diseases  of 
the  respiratory  system  and  of  the  heart,  will  be  consid- 
ered as  follows :  Chapter  II.,  Percussion  in  Health  ; 
Chapter  III.,  Percussion  in  Disease ;  Chapter  IV.,  Aus- 
cultation in  Health  ;  Chapter  Y.,  Auscultation  in  Dis- 
ease; Chapter  VI.,  The  Physical  Diagnosis  of  the  Dis- 
eases of  the  Kespiratory  System ;  Chapter  VIL,  The 
Physical  Conditions  of  the  Heart  in  Health  and  Dis- 
ease; Chapter  VIII.,  The  Physical  Diagnosis  of  Dis- 
eases of  the  Heart;  and,  as  properly  embraced  in  the 
scope  of  this  treatise.  Chapter  IX.  will  be  devoted  to 
the  Diagnosis  of  Thoracic  Aneurisms. 


38  PERCUSSION    IN    HEALTn. 


CHAPTER  11. 

PEECrSSION  IN  HEALTH. 

Percussion  with  the  fingers  or  with  a  percussor  and  pleximeter — The 
normal  vesicular  resonance  on  percussion ;  its  distinctive  characters 
relating  to  intensity,  pitch,  and  quality — Variations  in  the  charac- 
ters of  the  normal  vesicular  resonance  in  difi'crent  persons — Rela- 
tion of  the  pitch  of  resonance  to  the  vesicular  quality — Tympanitic 
resonance  over  the  ahdomen — Variations  of  the  normal  resonance  in 
the  different  regions  of  the  chest — Enumeration  of  the  regions  in 
which  the  resonance  on  the  two  sides  varies,  and  those  in  which  it 
is  identical  in  health— Influence  of  age  on  the  normal  resonance — 
Influence  of  the  acts  of  respiration  on  the  resonance — Rules  in  the 
practice  of  percussion. 

Percussion  may  be  performed  with  either  the  fingers 
or  artificial  instruments.  The  fingers  suffice  for  the  study 
and  in  ordinary  practice.  Instruments  are  preferable 
only  when  it  is  desired  to  produce  sounds  to  be  heard  at 
a  distance,  as  in  class  illustrations,  and  when,  from 
the  number  of  patients  to  be  percussed,  as  in  dispensary 
or  hospital  practice,  the  frequent  repetition  of  the  blows 
renders  the  fingers  tender  and  painful.  The  instruments 
area  pleximeter  and  a  percussor.  The  simplest  and  most 
convenient  pleximeter  is  an  oval  disk  of  ivory  or  hard 
india-rubber,  with  projecting  handles  or  auricles  suffi- 
ciently large  and  roughened  on  their  outer  aspect  so  as 
to  be  conveniently  held  by  the  fingers.  The  author  has 
lately  used  with  satisfaction  a  pleximeter  consisting  of 
a  piece  of  hard  rubber  bent  upward  at  one  extremity, 
and  ending  in  a  handle.  Tiie  best  percussor  is  a  double 
cone  of  caoutchouc  inclosed  by  a  ring,  with  a  handle  of 
convenient  length   and   size,  the  ring  and   the   handle 


NORMAL    RESONANCE.  39 

made  of  vulcanized  rubber.  The  instrument  is  very 
durable.  When  percussion  is  performed  with  the  fin- 
gers, the  palmar  surface  of  one  or  more  of  those  of  the 
left  hand  should  ba  applied  to  the  chest,  with  pressure 
sufficient  to  condense  the  soft  structures,  and  the  blows 
are  given  with  one  or  more  of  the  fingers  of  the  right 
hand  bent  at  the  second  phalangeal  joint  so  as  to  form  a 
riofht  anofle.  In  trivins:  the  blows,  the  movements  should 
be  limited  to  the  wrist-joint,  the  ends,  not  the  pulp,  of 
the  percussing  fingers  being  brought  into  contact  with 
the  dorsal  surface  of  the  finger  or  fingers  applied  to  the 
chest.  The  percussing  fingers  should  be  withdrawn  in- 
stantly the  blow  is  given.  The  type  of  perfect  percus- 
sion is  the  movement  of  the  hammers  when  the  keys  of 
a  piano-forte  are  struck.  The  force  of  the  percussion 
should  never  be  sufficient  to  give  pain  to  the  patient ; 
generally  either  light  or  moderately  forcible  blows  suf- 
fice. The  requisite  tact  in  the  performance  of  percus- 
sion is  acquired  by  a  litle  practice. 

The  first  object  in  the  study  of  percussion  is  to  become 
acquainted  with  the  characters  which  are  distinctive  of 
the  sound  obtained  thereby  from  the  healthy  chest.  For 
this  object  the  percussion  may  be  made  either  in  the  in- 
fra-clavicular region  of  either  side,  or  in  the  infra-scapu- 
lar region,  the  sound  in  these  situations  being  louder 
than  in  other  regions.  Percussion  being  performed,  a 
sound  or  resonance  is  produced.  This  sound  or  reso- 
nance is  now  to  be  analyzed  with  reference  to  characters 
derived  from  intensity,  pitch,  and  quality.  What  are 
these  characters?  The  intensity  will  depend,  other 
things  being  equal,  on  the  force  of  the  blow;  the  reso- 
nance is  comparatively  feeble  with  a  slight,  and  loud 
with  a  strong,  percussion.     Other  circumstances  affect 


40  PERCUSSION    IN    HEALTH. 

the  intensity,  irrespective  of  the  force  of  the  blow, 
namely,  the  volume  of  the  lung,  the  elasticity  of  the  cos- 
tal cartilages,  and  the  thickness  of  the  soft  parts  which 
cover  the  chest.  Owing  to  these  circumstances,  the  in- 
tensity of  the  resonance  is  by  no  means  similar,  in  the 
same  situation,  in  all  healthy  persons  ;  it  is  comparatively 
feeble  in  some  and  loud  in  others.  There  is  nothing  dis- 
tinctive of  this  normal  resonance  to  be  derived  from  inten- 
sity, and  we  say,  therefore,  that  the  intensity  is  variable. 

What  is  the  pitch  of  tliis  normal  resonance?  The  pitch 
of  a  sound  is  always  relative;  and,  comparing  this  reso- 
nance with  all  the  morbid  signs  obtained  by  percussion, 
it  is  lower  in  pitch.  We  say,  therefore,  that  the  pitch 
of  this  normal  resonance  is  low.  The  pitch,  howevc^r, 
is  found  to  vary  in  different  healthy  persons. 

What  is  the  quality  of  this  normal  resonance?  It  has 
a  quality  which  is  peculiar  to  it.  In  this  respect  it  is 
not  identical  with  any  sound  produced  otherwise  than  by 
percussion  over  healthy  lung  either  within  or  without  the 
chest.  The  quality  cannot,  therefore,  be  learned  by  an- 
alogv,  nor  can  it  be  described ;  it  can  only  be  appreciated 
by  direct  observation.  The  peculiar  quality  is  due  to 
the  fact  that  the  resonance  is  from  air  contained  in  the 
pulmonary  vesicles.  This  arrangement  causes  the  pecu- 
liar quality,  just  as  the  construction  of  any  particular 
musical  instrument  causes  the  quality  of  tone  peculiar  to 
that  instrument;  hence,  as  it  is  convenient  to  give  the 
quality  a  name,  we  call  it  the  vesicular  quality.  This 
quality  is  not  equally  marked  in  all  healthy  persons, 
being  as  a  rule  more  marked  in  proportion  to  the  inten- 
sity of  the  resonance. 

The  normal  resonance,  then,  obtained  by  percussion, 
may  be  thus  defined : 


VARIATIONS    IN    NORMAL    RESONANCE.  41 

A  resonance  of  v^ariable  intensity,  low  in  pitch  and 
having  a  peculiar  quality  called  vesicular.  The  word 
vesicular  is  frequently  embraced  in  the  name  of  this 
healthy  sign  ;  it  is  also  called  the  normal  resonance,  the 
normal  pulmonary  resonance,  or  the  normal  vesicular 
resonance.     The  last  of  these  names  is  to  be  preferred. 

The  normal  vesicular  resonance  on  percussion,  as  has 
been  seen,  is  not  uniform  in  all  healthy  persons ;  not 
only  is  its  intensity  variable,  but  it  varies  in  pitch  and 
in  the  amount  of  vesicular  quality.  This  may  be  easily 
illustrated,  by  percussing  successively  in  the  same  situa- 
tion, and  with  the  same  force,  a  series  of  persons  who 
are  assumed  to  be  free  from  disease.  Is  there  not  in 
this  fact  an  obstacle  in  practically  determining  this 
healthy  sign  ?  The  fact  occasions  no  embarrassment  for 
this  reason  :  we  determine,  in  each  case,  that  the  reso- 
nance is  normal  by  a  comparison  of  the  two  sides  of  the 
chest,  percussing  in  corresponding  situations  on  the  two 
sides  and  with  the  same  force.  There  is  no  abstract 
standard  of  the  normal  vesicular  resonance,  but,  by  com- 
paring the  two  sides  of  the  chest,  the  standard  of  health 
proper  to  each  person  is  obtained.  The  laws  of  disease 
are  such  that,  for  all  practical  purposes,  the  standard  of 
health  is  in  this  way  almost  always  available.  Notwith- 
standing the  variations  within  the  range  of  health,  the 
lowness  in  pitch  and  the  vesicular  quality  are  sufficiently 
distinctive  of  this  normal  sign  as  compared  with  the 
morbid  signs. 

The  pitch  of  the  vesicular  resonance  and  its  vesicular 
quality  are  in  a  uniform  relation  to  each  other;  that  is, 
the  conditions  giving  rise  to  the  peculiar  quality,  also 
render  the  pitch  low.  In  proportion  as  the  vesicular 
quality  is  marked,  the  pitch  is  lowered,  and,  conversely, 


42  PERCUSSION    IN    HEALTH. 

with  diminution  of  the  vesicular  quality  the  pitch  is  rel- 
atively higher.  This  relation  between  the  pitch  and 
quality  will  be  found  to  hold  good  in  the  resonance 
modified  by  disease  as  well  as  in  health.  Another  rela- 
tion may  be  here  stated,  namely,  whenever,  in  health  or 
disease,  a  tympanitic  quality  is  combined  with  the  vesic- 
ular, and  in  proportion  as  the  former  predominates,  the 
pitch  of  the  resonance  is  raised. 

The  pitch  and  quality  of  the  normal  vesicular  reso- 
nance may  be  readily  illustrated  by  percussing  succes- 
sively over  the  chest  and  the  abdomen.  The  different 
sections  of  the  alimentary  canal  generally  containing 
more  or  less  gas,  a  resonance  is  obtained  by  percussion 
over  the  abdomen.  This  resonance  is,  of  course,  devoid 
of  the  vesicular  quality;  in  contradistinction  to  the 
latter,  its  quality  is  called  tympanitic.  This  tympanitic 
resonance  is  not  uniform  in  all  parts  of  the  abdomen, 
but  everywhere  the  quality  is  tympanitic,  that  is,  non- 
vesicular, and  the  pitch  is  everywhere  higher  than  that 
of  the  normal  vesicular  resonance.  The  tympanitic 
resonance  over  the  stomach  is  generally  high  in  pitch, 
and  frequently  has  a  ringing  or  metallic  intonation. 
The  gastric  tympanitic  resonance  recognized  by  these 
characters,  will  be  found  to  be  involved  frequently  in 
sounds  produced  by  percussing  over  the  chest.  Gas  in 
the  caecum  gives  a  still  higher  pitch  of  resonance.  Over 
the  colon  the  resonance  is  lower  than  over  the  caecum 
and  stomach,  and  it  is  still  lower  over  the  small  intes- 
tines. In  all  these  situations,  bringing  the  tympanitic 
in  contrast  with  the  normal  vesicular  resonance,  tlie 
peculiar  quality  of  the  latter  and  its  lowness  of  pitch  are 
rendered  apparent.  The  term  tympanitic  resonance  will 
be  found  to  enter  into  the  names  of  two  of  the  morbid 
signs  obtained  by  percussion. 


RESONANCE  IN  DIFFERENT  REGIONS.     43 

Having  stiuliod  the  characters  of  the  normal  vesicular 
resonance,  and  become  practically  familiar  with  them  by 
percussing  different  healthy  persons,  the  student  should 
study  the  variations  which  this  resonance  presents  in  the 
different  regions  of  the  chest.  In  doing  this  he  acquires 
more  and  more  tact  in  the  performance  of  percussion, 
and  becomes  more  and  more  familiar  with  the  characters 
in  general  of  the  normal  vesicular  resonance. 

Sitprctf  or  Post-clavicular  Region. — The  resonance 
here  varies  much  in  intensity  in  different  persons.  The 
vesicular  quality  is  most  marked  in  the  central  portions. 
Towards  the  sternal  extremity  the  resonance  acquires  a 
tympanitic  quality  from  the  proximity  to  the  trachea ; 
it  bec^omes  vesiculo-tympanitic,  a  term  which  will  be 
applied  to  one  of  the  morbid  signs. 

Clavicular  Region. — Near  the  sternum  the  resonance 
is  somewhat  tympanitic  from  the  proximity  to  tlie  tra- 
chea. At  the  central  portion  the  vesicular  quality  is 
more  or  less  marked,  and  the  intensity  is  diminished  at 
the  acromial  extremity. 

Infra-clavicular  Region. — The  resonance  in  this  re- 
gion is  more  intense  than  elsewhere,  except  in  the  axil- 
lary and  the  infra-scapular  regions.  The  vesicular 
quality  is  combined  with  a  tympanitic  quality  toward 
the  sternum,  the  latter  being  derived  from  the  primary 
and  secondary  bronchi.  As  always  when  the  vesicular 
and  the  tympanitic  quality  are  combined,  the  pitch  is 
raised.  This  combination  in  health  and  disease  is  rec- 
ognized by  the  intensity,  pitch,  and  quality. 

Scapular  Region. — The  resonance  in  this  region  is 
notably  less  intense  than  in  the  infra-clavicular  region, 
owing  to  the  presence  of  the  scapula  and  its  muscles.  In 
proportion  as  the  intensity  is  less,  the  vesicular  quality 


44  PERCUSSION    IN    HEALTH. 

is  less  marked.  The  resonance  in  health,  however,  is 
quite  sufficient  for  morbid  signs  to  be  available  in  this 
situation. 

Inter-scapular  Region. — The  resonance  in  this  region 
is  weak  in  comparison  with  other  regions,  except  the  scap- 
ular, owing  to  the  muscles  which  here  cover  the  chest. 
In  the  upper  part  of  the  region  the  resonance  is  somewliat 
tympanitic  from  the  relation  to  the  trachea  and  bronchi. 

Mamriuiry  Region. — The  right  and  the  left  mammary 
retrion  are  to  be  studied  with  reference  to  differences  re- 
lating  to  the  liver  and  the  heart.  On  the  right  side, 
from  the  fourth  rib  downward,  the  resonance  is  dimin- 
ished, the  convex  extremity  of  the  liver  extending  up  to 
this  heiirht.  At  or  a  little  below  the  lower  border  of 
this  region  on  the  mammary  line,  that  is,  a  vertical  line 
passing  through  the  nipple,  resonance  ceases,  the  lower 
lobe  of  the  right  lung  not  extending  below  this  point. 
Between  the  third  and  fifth  ribs  on  this  side  near  the 
sternum,  the  resonance  is  diminished,  from  the  presence 
of  a  portion  of  the  right  auricle  and  ventricle.  On 
the  leftside  the  resonance  is  diminished,  within  the  pre- 
cordial space.  This  space  extends  vertically  from  the 
third  rib  to  the  fifth  intercostal  space,  and  horizontally 
from  the  sternum  to  a  point  at  or  a  little  within  the  mam- 
mary line.  The  resonance  is  considerably  diminished 
within  what  is  called  the  superficial  cardiac  space.  This 
space  is  represented  by  a  right-angled  triangle,  the  right 
angle  formed  by  a  vertical  line  drawn  from  a  point  on 
the  median  line  intersected  by  a  horizontal  line  connect- 
ing the  fourth  ribs,  and  a  horizontal  line  intersecting 
the  point  of  apex-beat  in  the  fifth  intercostal  space;  an 
oblique  line  drawn  from  the  centre  of  the  sternum  on  a 
level   with  the  fourth  rib  and  the  point  of  apex-beat 


RESONANCE    IN    DIFFERENT    REGIONS.  45 

forms  the  hypothenusc  of  the  right-angled  triangle. 
Within  this  space  the  heart  is  in  contact  witli  the  tho- 
racic wall.  Without  this  space  and  within  the  prsecor- 
dia  the  heart  is  covered  with  lung,  and  the  resonance 
on  percussion  is  less  diminished.  It  is  a  useful  exer- 
cise for  the  student  to  observe  the  diminution  of  the 
area  of  the  superficial  cardiac  space  by  a  forced  in- 
spiration, as  determined  by  percussion.  Aside  from 
the  presence  of  the  heart  and  the  convex  extremity  of 
the  liver,  the  resonance  over  the  mammary  is  less  than 
in  the  infra-clavicular  region,  being  diminished  by  the 
pectoral  muscle,  which  varies  considerably  in  bulk  in  dif- 
ferent persons,  and  in  women  by  the  mammary  gland, 
tlie  size  of  the  latter  varying  very  much  in  different 
women.  The  development  of  the  mammoe,  however,  is 
never  so  great  as  to  preclude  the  useful  employment  of 
percussion  in  this  region. 

Infra-mammary  Region. — In  this  region,  as  in  the 
region  above  it,  the  two  sides  present  notable  differences 
owing  to  the  situation  of  organs  below  the  diaphragm. 
On  the  right  side,  over  the  greater  part,  and  sometimes 
the  whole  of  tliis  region,  resonance  is  wanting,  that  is, 
percussion  gives  flatness.  It  is  easy  to  delineate  the 
boundary  between  the  lower  border  of  the  right  lung 
and  the  liver,  or  as  it  is  called,  the  line  of  hepatic  flat- 
ness. It  is  also  easy  to  distinguish  above  this  line  the 
height  to  which  the  lower  extremity  of  the  liver  extends, 
or,  as  it  is  called,  the  line  of  hepafie  diilncss.  The  situa- 
tion of  both  these  lines  varies  considerably  in  different 
healthy  persons.  The  distance  between  the  two  lines  is 
from  one  to  two  inches.  Both  lines  are  affected  consid- 
erably by  a  forced  inspiration  and  a  forced  expiration. 
A  forced  inspiration  depresses  the  line  of  flatness  about 


46  PERCUSSION    IN    HEALTH. 

one  and  a  half  inch.  A  forced  inspiration  causes  the 
line  to  rise  from  two  and  a  half  to  five  and  a  half  inches. 
The  distance,  therefore,  between  this  line  at  the  end  of 
a  forced  expiration,  and  at  the  end  of  a  forced  inspira- 
tion varies  from  four  to  seven  inches.  With  reference 
to  the  practice  of  percussion,  as  well  as  for  the  purpose 
of  verification,  these  points  should  be  studied.  Not  in- 
frequently percussion  over  the  right  infra-mammary 
region  yields  a  tympanitic  resonance  due  to  the  disten- 
sion with  gas  of  the  transverse  colon. 

On  the  left  side,  the  resonance  in  this  region  varies  in 
different  persons,  in  the  same  persons  at  different  times, 
and  in  different  portions  of  the  region  at  the  same  time, 
the  variations  depending  on  the  organs  below  the  dia- 
phragm. Flatness  is  caused  by  the  extension  of  the  left 
lobe  of  the  liver  into  this  region  about  three  inches  to  the 
left  of  the  median  line.  The  left  portion  of  the  region 
is  in  relation  to  the  spleen,  an  organ  which  varies  con- 
siderably in  size  in  health  as  well  as  disease,  its  average 
dimensions  being  about  four  inches  in  length  and  three 
inches  in  width.  Between  the  spleen  and  the  liver  lies 
the  stomach,  the  volume  of  which  is  constantly  fluctuat- 
ing, owing  to  its  varying  solid,  liquid,  and  gaseous  con- 
tents. Distension  of  the  stomach  with  gas  occasions  a 
tympanitic  resonance  which  frequently  is  transmitted 
above  into  the  mammary  region  in  health  as  well  as  in 
disease.  The  space  corresponding  to  the  spleen  is  de- 
termined by  the  vesicular  resonance  above  and  the  tym- 
panitic resonance  below,  the  latter  boundary,  however, 
not  being  very  reliable  on  account  of  the  ready  conduc- 
tion of  tympantic  resonance  for  a  certain  distance.  The 
distension  of  the  stomach  with  solid  or  liquid  contents,  of 
course,  occasions  flatness.     The  study  of  the  infra-mam- 


RESONANCE    IN    DIFFERENT    REGIONS.  47 

mary  regions  with  reference  to  the  variations  in  resonance 
arising;  from  the  relations  to  the  oro-ans  below  the  dia- 
phragm,  is  of  much  utility  from  the  practice,  as  well  as 
the  knowledge,  which  it  involves.  The  exercise,  of  en- 
deavoring to  define  the  boundaries  of  these  different  or- 
gans in  healthy  persons,  will  be  of  great  service  to  the 
student  in  acquiring  tact  in  percussion,  and  in  discrimi- 
nating differences  in  the  sounds  obtained  by  this  method. 

Sternal  Regions. — In  the  upper  sternal  region,  that  is, 
above  the  lower  margin  of  the  second  rib,  the  resonance 
is  non-vesicular,  being  derived  from  air  in  the  trachea 
above  the  point  of  bifurcation.  Being  non-vesicular, 
it  is,  of  course,  tympanitic,  this  term  embracing  all 
sounds  which  are  devoid  of  the  vesicular  quality.  Be- 
tween the  second  and  third  ribs,  the  inner  borders  of  the 
two  lungs  approximating,  the  resonance  has  a  vesicular 
quality  more  or  less  marked  ;  but  owing  to  the  remnant 
of  the  thymus  gland,  together  with  adipose  substance, 
and  the  presence  of  the  large  vessels,  the  resonance  is 
not  intense  in  this  situation.  Below  the  third  rib  the 
resonance  has  modifications  due  to  the  combination  of 
several  different  organs  situated  beneath  the  lower  sternal 
region.  On  the  right  side  of  the  mesial  line  is  the  inner 
border  of  the  right  lung,  the  greater  part  of  the  right 
and  a  portion  of  the  left  ventricle  of  the  heart  lying 
beneath  ;  a  portion  of  the  liver  extends  into  the  lower 
part  of  this  region,  and  a  portion  of  the  stomach  when 
distended.  The  resonance  thus  varies  in  different  situa- 
tion.s,  and  often  presents  a  mixed  character.  It  is  a  use- 
ful exercise  to  endeavor  to  define  by  percussion  the 
boundaries  of  the  several  organs  which  are  here  in  jux- 
taposition. 

Infra- scapular  Regions. — The    resonance  below  the 


48  PERCUSSION    IN    HEALTH. 

scapula  is  intense  as  compared  with  that  over  the  scapula, 
and  the  vesicular  quality  is  marked.  The  resonance  ex- 
tends to  the  eleventh  rib,  which  is  the  lower  boundary  of 
the  lung.  On  the  right  side,  at  or  near  this  point,  is  the 
line  of  hepatic  flatness,  hepatic  dulness  extending  from 
one  to  two  inches  above  this  line.  The  line  of  hepatic 
flatness  and  of  hepatic  dulness  is  lowered  from  one  to 
two  inches  by  a  deep  inspiration,  and  raised  by  a  forced 
expiration.  On  the  left  side  the  resonance  may  receive 
a  tympanitic  quality  from  the  presence  of  gas  in  the 
stomach. 

Lateral  Regions. — In  these  regions  the  resonance  is 
relatively  intense,  and  notably  vesicular.  On  the  right 
side  the  line  of  hepatic  flatness  is  at  the  eighth  rib, 
hepatic  dulness  extending  above  this  line  as  in  front  and 
behind.  On  the  left  side  the  resonance  may  be  rendered 
somewhat  dull  by  the  presence  of  the  spleen,  but  it 
oftener  acquires  a  tympanitic  quality  from  the  presence 
of  gas  in  the  stomach. 

As  has  been  stated,  the  normal  vesicular  resonance  is 
not  in  all  persons  identical  as  regards  intensity,  pitch, 
and  quality.  There  is,  therefore,  no  fixed  standard  in 
these  respects  by  which  we  can  determine  whether  the 
resonance  be  normal  or  not.  The  standard  proper  to 
each  person  is  to  be  ascertained  by  a  comparison  of  the 
two  sides  of  the  chest;  each  person,  in  other  words, 
furnishes  his  own  standard  of  health.  But  it  is  to  be 
observed,  that  all  the  regions  do  not  normally  correspond 
in  respect  of  the  resonance  on  the  two  sides.  In  the 
following  regions  the  resonance  is  notably  dissimilar  on 
the  two  sides:  The  mammary,  the  infra-mammary,  the 
infra-axillary,  and  the  infra-scapular.  On  the  other 
hand,  in  the  following  region  the  resonance  on  the  two 


RESONANCE    IN    DIFFERENT    REGIONS.  49 

sides  is  nearly  or  quite  identical :  The  supra-clavicular, 
clavicular  and  infra-clavicular,  the  scapular  and  inter- 
scapular, and  the  axillary.  In  some  of  the  latter  the 
resonance  has  normally  some  points  of  disparity,  and  it 
is  of  practical  importance  to  note  the  small  dissimilarity 
which  thus  belongs  to  health.  This  statement  applies 
especially  to  the-infra-clavicular  region,  a  region  which, 
as  will  be  seen  hereafter,  is  of  great  importance  with 
reference  to  the  signs  of  phthisis.  In  this  region  the 
resonance  on  the  left  side  is  somewhat  more  intense, 
more  vesicular,  and  lower  in  pitch  than  is  the  resonance 
on  the  right  side ;  per  contra^  the  resonance  is  less  intense, 
less  vesicular,  and  higher  on  the  right  side.  This  dis- 
parity is  observable  in  all  persons,  but  is  more  marked 
in  some  than  in  others.  The  student  should  becouie 
practically  familiar  with  this  normal  difference  between 
the  two  sides,  and  in  becoming  so,  the  practical  experi- 
ence acquired  in  performing  percussion  will  be  of  use. 

The  normal  resonance  is  affected  by  age.  In  early 
life,  when  the  costal  cartilages  are  flexible  and  elastic, 
the  resonance  is  more  intense  and  lower  in  pitch  than  in 
old  a2;e,  when  the  cartilao:es  are  rio;id  and  the  vesicular 
structure  of  the  lung  more  or  less  atrophied. 

The  resonance  varies  considerably  in  the  different 
regions  at  the  end  of  a  full  inspiration  and  at  the  end  of 
a  forced  expiration.  With  regard  to  this  disparity,  the 
following  is  an  extract  from  a  work  on  physical  explora- 
tion, published  by  the  author  in  1856  : 

''  The  percussion-sound  may  also  be  found  to  vary  at 
different  periods  of  an  act  of  respiration  in  the  same 
individual.  The  quantity  of  air  contained  within  the 
air-cells,  and  consequently  the  relative  proportion  of  air 
and  solids,  are  by  no  means  equal  after  a  full  inspiration 


60  PERCUSSION    IN    HEALTH. 

and  after  a  forced  expiration.  This  difference  in  lung 
expansion  may  occasion  an  appreciable  disparity  in  reso- 
nance, according  as  the  percussion  is  made  at  the  conchi- 
sion  of  a  full  inspiration,  or  a  forced  expiration.  The 
disparity  is  not  appreciable  uniformly  in  different  persons. 
This  fact  I  have  ascertained  by  noting  the  results  of 
examinations  made  with  reference  to  the  point.  When 
it  does  exist,  it  usually  consists,  contrary  to  what  might 
perhaps  have  been  anticipated,  and  the  reverse  of  what 
is  usually  stated  in  works  on  physical  exploration,  in 
diminished  resonance  and  elevation  of  pitch  at  the  con- 
clusion of  inspiration.  This  is  probably  to  be  explained 
by  the  greater  degree  of  tension  of  the  lungs  and  thoracic 
walls  produced  by  inspiration  voluntarily  prolonged  and 
maintained — aconditiou  presenting  physical  obstacles  to 
vSonorous  vibrations  more  than  sufficient  to  counterbalance 
the  increased  proportion  of  air  within  tlie  cells.  It  is  a 
curious  fact,  worthy  of  notice,  that  the  two  sides  of  the 
chest  are  not  always  found  to  be  affected  equally  as 
regards  the  percussion-sound,  at  the  conclusion  of  a  full 
inspiration,  contrasted  with  that  after  a  forced  expira- 
tion. I  have  observed  the  contrast  to  be  more  striking 
on  the  right  than  on  the  left  side ;  and  in  one  instance 
on  the  left  side,  the  resonance  was  less  intense  and  some- 
what tympanitic  after  a  full  inspiration,  while  on  the 
right  side  the  o])posite  effect  was  produced,  and  the 
sound  became  quite  dull  after  a  forced  expiration.  In 
view  of  these  variations  in  a  certain  proportion  of  in- 
stances incident  to  different  periods  of  a  single  act  of 
respiration,  in  some  cases  of  disease  in  which  it  is  de- 
sirable to  observe  great  delicacy  in  the  correspondence 
of  the  two  sides,  pains  should  be  taken  to  percuss  cor- 
responding points  at  a  similar  stage  of  respiration,  and 


KULES    IN    PRACTICE    OF    PERCUSSION.  51 

the  close  of  a  full  inspiration  is,  perhaps,  the  period  to 
be  preferred.  Ordinarily,  the  liability  to  error  from 
this  source  is  obviated,  either  by  repeating  a  series  of 
strokes,  first  on  one  side  and  next  on  the  other,  or  by 
percussing  both  sides  repeatedly  in  quick  succession,  in 
order  mentally  to  obtain  the  average  intensity  and  other 
characters  of  the  sound  during  the  successive  stages  of  a 
respiration.  The  instances  of  disease,  however,  are  ex- 
ceedingly rare,  in  which  such  nicety  of  discrimination  is 
important. ^^ 

Prof.  Da  Costa  has  recently  studied  more  fully  the 
variations  in  this  respect  in  the  different  regions  in  dis- 
ease as  well  as  in  health,  and  he  has  distinguished  this 
as  '^respiratory  percussion."^ 

Rules  in  the  Practice  of  Percussion. 

1.  Prior  to  a  comparison  of  the  two  sides  of  the  chest, 
as  regards  the  resonance  on  percussion,  either  in  health 
or  disease,  an  examination  by  inspection  should  be  made, 
in  order  to  determine  whether  there  be  any  deviation 
from  the  normal  conformation.  In  what  has  been  stated 
concerning  percussion  in  health,  it  is  assumed  that  the 
chest  is  symmetrical.  Want  of  symmetry  may  be  due 
to  congenital  deformities,  and  to  those  caused  by  rachitis, 
chronic  pleurisy,  curvature  of  the  spine,  and  injuries. 
Any  deviation  from  the  normal  conformation  will  affect 
more  or  less  the  resonance  in  corresponding  regions  on 
the  two  sides.  Due  allowance  is  to  be  made  for  want  of 
symmetry  in  determining  morbid  signs,  and  often  the 
existence  of  these  cannot  be  determined  with  positiveness 
when  there  is  considerable  deformity.     The  signs  ob- 

'  Vide  work  on  Diagnosis,  fourth  edition,  1876. 


52  PERCUSSION    IN    HEALTH. 

tained  by  auscultation  are  less  affected  by  want  of  sym- 
metry than  those  obtained  by  percussion. 

2.  Attention  to  the  position  of  the  person  examined  is 
important  with  reference  to  the  normal  symmetry  of  the 
chest.  If  the  person  be  standing  or  sitting,  the  position 
should  be  upright  and  the  shoulders  brought  to  a  level. 
A  little  inclination  of  the  body  to  one  side,  or  a  depres- 
sion of  one  shoulder,  will  be  found  to  affect  perceptibly 
the  normal  resonance,  when  the  two  sides  are  compared. 
If  the  body  be  recumbent,  it  should  be  as  near  as  possible 
on  a  level  plane.  These  conditions  are  indispensable 
for  a  nice  comparison  of  the  two  sides  either  in  iiealth  or 
disease. 

3.  In  making  a  nice  comparison,  the  person  who  per- 
cusses should  be,  as  nearly  as  possible,  directly  either  in 
front  or  behind  the  person  percussed.  Percussion  made 
by  one  standing  or  sitting  by  tlie  side  of  the  person  per- 
cussed, is  almost  certain  to  produce  disparity  in  resonance. 

4.  Percussion  made  successively  on  one  side,  and  the 
other  side,  must  be  in  all  respects  the  same,  in  regard  to 
the  mode,  the  force  of  the  blow,  and  the  situation,  A 
light  percussion  on  one  side,  and  a  strong  percussion  on 
the  other  side,  will,  of  course,  cause  a  disparity  in  the 
intensity  of  resonance.  The  percussion  must  be  made  in 
succession  at  points  as  nearly  as  possible  equidistant  from 
the  median  line,  and  from  the  summit  or  base  of  the  chest. 
With  reference  to  great  nicety,  the  percussion,  if  made 
on  the  rib  or  intercostal  space  on  one  side,  must  be  made 
on  the  rib  or  intercostal  space  on  the  other  side.  Great 
nicety  of  comparison  also  requires  that,  if  the  percussion 


RULES  IN  PRACTICE  OF  PERCUSSION.     53 

be  made  on  one  side  during  the  act  of  inspiration,  it 
should  be  made  on  the  other  side  during  this  act.  The 
signs  of  disease,  however,  are  generally  so  well  marked, 
that  very  close  attention  to  these  points  is  not  necessary. 

5.  A  series  of  blows  in  rapid  succession  (5  or  7)  is  to 
be  preferred  to  one  or  two,  in  j^racticing  percussion,  dif- 
ference in  intensity,  pitch,  and  quality  being  thereby 
better  appreciated. 

6.  Percussion  may  be  made  lightly  or  forcibly,  the 
former  being  called  superficial,  and  the  latter  deep  per- 
cussion. With  light  blows  the  resonance  comes  from  the 
superficies  of  the  lung,  and  from  within  a  limited  area. 
With  forcible  blows  the  resonance  is  from  a  greater  depth, 
and  a  wider  space.  The  results  of  these  different  modes 
of  practising  percussion  may  be  illustrated  within  the 
prsecordia  in  health.  Comparing  the  resonance  over  the 
superficial  cardiac  space  with  that  in  a  corresponding 
situation  on  the  right  side,  dulness  is  more  marked  with 
light  than  with  forcible  blows,  the  resonance  from  the 
latter  coming  from  a  wider  area.  On  the  other  hand, 
comparing  the  resonance  over  the  deep  cardiac  space, 
dulness  is  more  marked  with  forcible  than  with  li^ht 
blows,  owing  to  the  presence  of  lung  between  the  heart 
and  the  walls  of  the  chest.  This  rule  is  of  importance 
in  its  application  to  percussion  in  disease. 

7.  Percussion  over  the  anterior  portion  of  the  chest, 
the  person  percussed  leaning  against  a  door,  a  board 
partition,  or  a  lathed  wall,  gives  an  increased  intensity 
of  resonance.  It  is  often  useful  to  resort  to  this  proce- 
dure in  the  practice  of  percussion. 

5 


54  PERCUSSION    IN    DISEASE. 


CHAPTER  III. 
PERCUSSION  IN  DISEASE. 

Enumeration  of  the  signs  of  disease  furnished  by  percussion — Re- 
quirements for  a  practical  knowledge  of  these  signs — The  distinctive 
characters  of,  the  morbid  physical  conditions  represented  by,  and  the 
different  diseases  into  the  diagnosis  of  which  enter,  these  signs,  sev- 
erally, to  wit,  1.  Absence  of  resonance  or  flatness;  2.  Diminished 
resonance;  3.  Tympanitic  resonance;  4.  Vesiculo-tympanitic  reso- 
nance; 5.  Amphoric  resonance;  6.  Cracked-metal  resonance — Sense 
of  resistance  felt  in  the  practice  of  percussion,  as  a  morbid  sign. 

Percussion  in  disease  furnishes  signs  which  represent 
certain  of  the  morbid  physical  conditions  incident  to  the 
different  pulmonary  affections;  with  these  physical  con- 
ditions and  their  relations  to  pulmonary  affections  the 
student  is  supposed  to  be  familiar  {vide  page  19  et  seq.). 

The  signs  of  disease  furnished  by  percussion  are  re- 
solvable into  six,  namely:  1.  Absence  of  resonance  or 
flatness;  2.  Diminished  resonance  or  dulness  ;  3.  Tym- 
panitic resonance  ;  4.  Vesiculo-tympanitic  resonance ;  5; 
Amphoric  resonance,  and  6.  Cracked-metal  resonance. 
The  two  last  named  signs  are  properly  varieties  of  tym- 
panitic resonance,  but  it  is  most  convenient  to  consider 
them  as  distinct  signs. 

Knowledge  of  these  six  signs  sufficient  for  their  avail- 
ability in  physical  diagnosis  requires,  first,  a  practical 
acquaintance  with  the  characters  which  distinguish  each 
from  the  others,  as  well  as  from  the  normal  resonance; 
and  fiecondy  a  clear  apprehension  of  the  significance  of 


ABSENCE    OF    RESONANCE    OR    FLATNESS.          55 

each,  that  is,  the  morbid  physical  conditions  which  they 
severally  represent.  Under  tliese  two  asj)ects  the  signs 
will  now  be  considered. 

1.  Absence  of  Resonance  or  Flatness. 

This  sign  is  sufficiently  defined  by  its  name.  It  is 
absence  of  resonance  or  sound.  Nothing  is  heard  but  a 
noise  such  as  may  be  produced  by  percussing  over  a  solid 
mass,  for  example  a  limb  composed  of  muscle  and  bone, 
or  over  a  collection  of  liquid,  for  example  the  abdomen 
in  hydro-peritoneum  or  ascites.  There  being  no  reso- 
nance or  sound,  the  sign  has  no  characters  pertaining  to 
pitch  or  quality.  It  may  be  illustrated  on  the  healthy 
chest  by  percussing  in  the  right  infra-mammary  region 
below  the  line  of  hepatic  flatness. 

There  are  four  classes  of  morbid  physical  conditions 
giving  rise  to  flatness  on  percussion,  namely,  1st,  a  cer- 
tain quantity  of  liquid  either  in  the  pleural  sac,  or  in 
the  substance  of  the  lungs,  or  in  pulmonary  cavities :  2d, 
liquid  filling  the  air-vesicles;  3d,  complete  solidification 
of  lung;  and  4th,  a  tumor  within  the  chest.  Flatness  on 
percussion  always  represents  one  of  these  morbid  phys- 
ical conditions. 

These  conditions  are  incidents  to  different  diseases,  as 
follows  : 

1st.  Liquid  in  the  pleural  cavity  is  incident  to  pleurisy 
with  effusion,  empyema,  and  hydrothorax.  A  collection 
of  liquefied  exudation  within  the  lungs  is  incident  to 
phthisis.  A  collection  of  pus  constitutes  pulmonary 
abscess,  and  phthisical  cavities,  or  those  caused  by  cir- 
cumscribed gangrene,  may  become  filled  with  morbid 
liquid  products. 

2d.  Serous   effusion  into  the  air-vesicles  constitutes 


56  PERCUSSION    IN    DISEASE. 

pulmonary  oedema.  Liquid  blood  extravasated  charac- 
terizes hsemorrhagic  infarctus,  pneumorrhagia  or  pulmo- 
nary apoplexy.  Pus  infiltrating  more  or  less  of  the 
parenchyma  may  be  derived  from  an  abscess  either  within 
the  lung,  or  elsewhere,  for  example  the  liver,  and  from 
the  pleural  cavity  in  empyema  when  perforation  of  lung 
takes  place. 

3d.  Solidification  of  lung  occurs  in  pneumonia  from 
an  exudation  within  the  air-cells  ;  it  is  produced  by  con- 
densation from  compression  by  liquid  or  air  in  the  pleural 
sac,  the  pressure  of  a  tumor,  and  by  collapse;  it  exists 
in  cases  of  phthisis,  in  interstitial  pneumonia,  and  in 
carcinomatous  infiltration  of  lung. 

4th.  Tumors  within  the  chest  are  of  diflPerent  kinds, 
for  examples,  aneurisms  and  cancerous  growths.  In 
proportion  to  their  size  they  occupy  space  belonging  to 
the  lung,  as  well  as  condensing  the  latter  by  pressure. 
Flatness  may  also  be  caused  by  the  encroachment  of 
organs  situated  below  the  diaphragm  upon  the  thoracic 
space,  as  in  cases  of  enlargement  of  the  liver  and  spleen. 

Flatness  on  percussion  in  all  these  conditions  is  the 
same.  The  sign  alone  does  not  enable  us  to  discriminate 
the  conditions  from  each  other,  nor  to  determine  the  ex- 
isting disease. 

Finding  this  sign  present,  the  particular  condition  and 
the  disease  in  each  case  are  to  be  determined  by  the 
situation  of  the  riatness,  its  extent,  the  associated  physi- 
cal signs  furnished  by  auscultation,  together  wntli  the 
other  methods  of  exploration,  and  by  the  symptomatic 
phenomena. 


DIMINISHED    RESONANCE    OR    DULNESS.  57 

2.  Diminished  Resonance  or  Dulness. 

The  resonance  on  percussion  is  diminislied,  or  there  is 
dulness,  when  the  solids  or  liquids  within  the  chest  are 
morbidly  increased  without  increase  in  the  quantity  of 
air,  the  increased  amount  of  solids  or  liquids  not  being 
suffi  jient  to  cause  flatness.  Diminution  of  air  without  in- 
crease of  either  solids  or  liquids,  as  in  collapse  of  pulmo- 
nary lobules,  also  gives  rise  to  dulness.  We  may  forrau- 
larize  the  physical  conditions  by  saying  that  they  consist 
in  an  abnormal  proportion  of  solids  or  liquids  over  the 
air  in  the  pulmonary  vesicles. 

Dulness  varies  in  degree.  It  may  be  slight,  moderate, 
considerable,  or  great.  These  adjectives  of  quantity  ex- 
press sufficiently  the  variations  in  this  regard.  The 
degree  of  dulness  corresponds  to  the  amount  of  the  rela- 
tive disproportion  of  solids  or  liquids  over  the  air  within 
the  chest. 

The  pitch  of  sound  is  higher  than  that  of  the  normal 
resonance  of  the  persons  percussed.  This  is  invariable; 
with  dulness  there  is  always  more  or  less  elavation  of 
pitch.  The  quality  is  altered  only  in  amount;  there  is, 
of  course,  less  vesicular  quality  in  proportion  as  the  in- 
tensity of  the  resonance  is  diminished. 

The  characters  which  distinguish  this  sign,  thus,  are, 
lessened  intensity  of  resonance,  elevation  of  pitch,  and 
weakened  vesicular  quality. 

The  morbid  conditions  giving  rise  to  this  sign  are  those 
which,  existing  in  a  greater  degree,  give  rise  to  flatness. 
Morbid  products  within  the  pleural  sac,  serum,  pus, 
lymph,  if  not  sufficient  to  cause  flatness,  give  rise  to  dul- 
ness. The  sign,  therefore,  occurs  in  pleurisy,  empyema, 
and  hydrothorax.  The  same  is  true  of  pulmonary  oedema, 
hemorrhagic  infarctus,  pneuraorrhagia,  and  purulent  in- 


68  PERCUSSION    IN    DISEASE. 

filtration  of  lung.  Solidification  of  lung,  when  not  com- 
plete, occasions  dulness  ;  hence  it  is  a  sign  in  pneumonia, 
vesicular  and  interstitial,  in  phthisis,  in  condensation  of 
lung  from  compression,  in  collapse  of  pulmonay  lobules, 
and  in  carcinomatous  infiltration.  A  tumor  within  the 
chest,  not  sufficiently  large  to  cause  flatness,  gives  rise 
to  dulness. 

There  are,  however,  some  conditions  giving  rise  to 
dulness,  which  are  never  sufficient  to  cause  flatness. 
Pulmonary  congestion  limited  to  a  lobe  may  diminish 
the  resonance  appreciably.  The  dulness  may  exist  in 
the  first  stage  of  pneumonia,  before  solidification  from 
pneumonic  exudation  has  taken  place.  A  layer  of  lymph 
upon  the  pleural  surfaces  causes  dulness  after  the  liquid 
effusion  in  pleurisy  has  been  removed,  and  after  the 
vesicular  exudation  in  pneumonia  is  absorbed.  Dulness 
may  also  be  caused  by  a  considerable  accumulation  of 
mucus  or  coagulated  blood  within  the  intra-pulmonary 
bronchial  tubes. 

The  particular  morbid  condition  which  gives  rise  to 
dulness  cannot  be  inferred  from  the  characters  of  the 
sisrn  :  the  si^rn  onlv  denotes  that  some  one  of  the  difler- 
ent  morbid  conditions  exists.  The  condition  which  ex- 
ists in  each  case,  and  the  disease,  are  to  be  determined 
by  the  situation,  extent,  and  degree  of  dulness,  taken  in 
connection  with  the  Information  derived  from  other 
methods  of  exploration  than  percussion,  together  with 
the  history  and  symptoms. 

3.  Tympanitic  Resonance. 

Resonance  is  tympanitic  whenever  it  is  entirely  devoid 
of  the  vesicular  quality;  in  other  words,  any  resonance 
which  is  non-vesicular  is  tympanitic.     The  leading  dis- 


TYMPANITIC    RESONANCE.  69 

tinctlve  character  of  the  preceding  sign  (dulness)  relates 
to  intensity,  whereas,  the  leading  distinctive  character 
of  this  sign  relates  to  quality.  Tympanitic  resonance 
derives  no  distinctive  character  from  intensity;  it  may 
be  either  more  or  less  intense  than  the  resonance  of 
health  in  the  person  percussed.  This  point  is  to  be  im- 
pressed, inasmuch  as  with  many  the  idea  of  a  tympan- 
itic resonance  involves  increased  intensity  of  sound  ;  a 
resonance,  be  it  never  so  feeble,  if  it  be  non-vesicular, 
is  tympanitic.  If,  however,  the  resonance  be  quite  fee- 
ble, it  is  not  always  easy  to  determine  whether  there  be, 
or  be  not,  any  appreciable  vesicular  quality.  The  term 
used  by  Stokes,  namely,  '^tympanitic  dulness,^^  is  prop- 
erly enough  applied  to  a  resonance  with  diminished  in- 
tensity, in  which  a  vesicular  quality  cannot  be  appreci- 
ated. As  regards  pitch,  a  tympanitic  resonance  is  higher 
than  the  normal  vesicular  resonance.  If  there  be  any 
exceptions  to  this  rule,  they  are  extremely  infrequent. 
The  tympanitic  resonance  over  different  parts  of  the  ab- 
domen is  always  higher  in  pitch  than  the  resonance  over 
healthy  lung. 

The  following  are  the  morbid  physical  conditions 
which  give  rise  to  tympanitic  resonance: 

1st.  Air  in  the  pleural  cavity.  It  is,  therefore,  a 
sign  of  pneumothorax.  Frequently,  in  this  affection, 
the  tympanitic  resonance  is  more  intense  than  the  reso- 
nance of  health,  the  pitch  being  more  or  less  raised. 

2d.  Pulmonary  cavities  containing  air.  It  occurs, 
therefore,  in  cases  of  phthisis.  In  this  disease  the  tym- 
panitic resonance  is  limited  to  a  circumscribed  space  cor- 
responding to  the  site  and  size  of  the  cavity,  whereas,  in 
pneumothorax,  it  frequently  exists  over  a  considerable 
part  or  the  whole  of  the  affected  side  of  the  chest. 


60  PERCUSSION    IN    DISEASE. 

3cl.  Comj)lete  solidification  of  the  whole  or  a  part  of 
the  upper  lobe  of  a  lung.  The  tympanitic  resonance, 
under  these  circumstances,  must  be  derived  from  the  air 
in  the  lower  part  of  the  trachea  and  the  bronchial  tubes 
exterior  to  the  lungs.  This  is  the  explanation  of  the 
sign  in  the  second  stage  of  pneumonia  affecting  an  upper 
lobe,  and  in  certain  cases  of  phthisis  prior  to  the  stage 
of  excavation.  Dilatation  of  the  intra-pulmonary  bron- 
chial tubes,  with  solidification  surrounding  them,  as  in 
some  cases  of  interstitial  pneumonia  or  cirrhosis  of  lung, 
may  give  rise  to  tympanitic  resonance. 

4th.  Conduction  of  resonance  from  the  stomach  or 
colon  containing  air  or  gas.  A  gastric  tympanitic  reso- 
nance is  frequently  conducted  over  a  part,  and  some- 
times over  the  whole,  of  the  left  side  of  the  chest.  This 
is  more  likely  to  occur  when  the  left  lung  is  solidified. 
On  the  right  side  less  frequently  a  tympanitic  resonance 
may  be  conducted  upward  from  the  colon  to  a  greater  or 
less  extent. 

4.  Vesiculo-Tympanitic  Resonance. 

This  name  was  proposed  by  the  author  many  years 
ago  to  denote  a  sign  with  the  following  distinctive  char- 
acters :  The  resonance  increased  in  intensity ;  the  quality, 
a  combination  of  the  vesicular  with  a  tympanitic,  and 
the  pitch  high  in  proportion  as  the  tympanitic  quality 
predominates  over  the  vascular. 

The  sign  represents  especially  one  morbid  physical 
condition,  namely,  an  abnormal  accumulation  of  air 
in  consequence  of  dilatation  of  the  air-vesicles,  that  is, 
pulmonary  or  vesicular  emphysema.     The  sign  also  is 


AMPHORIC    RESONANCE.  61 

present  in  interstitial  or  interlobniar  emphysema.  The 
relation  of  the  si^n  to  these  adections  renders  it  of  sreat 
value  in  physical  diagnosis. 

A  vesiculo-tympanitic » resonance  is  obtained,  when 
tlie  pleural  sac  is  partially  filled  with  liquid,  by  percuss- 
ing over  the  lung  on  the  affected  side.  Although  the 
pressure  of  the  liquid  diminishes  the  volume  of  the  lung, 
as  a  rule  it  yields  this  sign.  The  resonance  is  vesiculo- 
tympanitic above  the  liquid  when  the  latter  is  sufficient 
to  fill  a  third,  a  half,  or  even  two-thirds  of  the  intra- 
thoracic space.  The  sign  is  also  obtained  over  the  upper 
lobe  when  the  lower  lobe  is  solidified  in  the  second  stage 
of  pneumonia,  and  over  the  lower  lobe  when  the  upper 
lobe  is  solidified. 

5.  Amphoric  Resonance. 

Resonance  is  said  to  be  amphoric  when  it  has  a  musi- 
cal intonation  analogous  to  that  produced  by  blowing 
over  the  mouth  of  an  empty  bottle.  An  amphoric  sound 
is  easily  illustrated  by  filliping  the  cheek  made  tense, 
the  mouth  not  completely  closed,  and  the  jaws  separated, 
as  is  done  when  the  sound  of  a  liquid  fiowing  from  a 
bottle  is  imitated.  By  varying  the  size  of  the  cavity  of 
the  mouth,  the  amphoric  sound  thus  })roduced  may  be 
made  to  vary  much  in  pitch.  This  illustration  exempli- 
fies the  mechanism  of  the  sign  in  disease. 

The  sign  represents  a  pulmonary  cavity  which  is  gen- 
erally phthisical.  The  conditions,  aside  from  the  exist- 
ence of  the  cavity,  are,  rigidity  of  its  walls,  so  that  they 
do  not  collapse,  the  presence,  of  course,  of  air  within  the 
cavity,  and  free  communications  with  the  bronchial 
tubes.     These  accessory  conditions  are  not  constant,  so 

G 


62  PERCUSSION    IN    DISEASE. 

that  an  amphoric  resonance  over  a  cavity  is  sometimes 
found,  and  other  times  wanting.  Directly  after  having 
been  wanting,  it  may  be  reproduced  if  the  patient  expec- 
torate freely.  ' 

When  percussion  is  made  with  reference  to  this  sign, 
the  mouth  of  the  patient  should  be  open,  and  one  or  two 
rather  forcible  blows  are  better  than  a  series  of  four  or 
six.  The  amphoric  sound  may  be  often  distinctly  per- 
ceived if  the  ear  be  brought  into  close  proximity  to  the 
patient's  open  mouth,  when  the  sign  is  not  apj^reciable 
otherwise.  It  may  be  rendered  still  more  distinct  by 
means  of  the  binaural  stethoscope,  the  pectoral  extremity 
being  close  to  the  mouth  of  the  patient. 

As  a  cavernous  sign  the  amphoric  resonance  is  very 
reliable;  but  it  does  not  invariably  denote  a  pulmonary 
cavity.  It  is  obtained  in  some  cases  of  pneumothorax, 
the  pleural  space  filled  with  air  forming  a  cavity  which 
communicates  wnth  the  bronchial  tubes  through  a  per- 
foration of  the  lung  situated  above  the  level  of  the  liquid. 
It  is  sometimes  obtained  over  a  solidified  portion  of  lung 
situated  in  close  proximity  to  a  primary  bronchus,  the 
resonance  being  derived  from  the  air  within  the  latter. 
It  is  occasionally  produced  by  percussing  over  the  site 
of  the  primary  bronchus  in  the  second  stage  of  pneu- 
monia affecting  an  upper  lobe.  In  children,  owing  to 
the  yielding  of  the  costal  cartilages,  it  may  even  be  pro- 
duced in  health  over  a  primary  bronchus.  In  all  these 
exceptional  instances,  the  associated  signs  and  symptoms 
will  prevent  the  error  of  attributing  the  sign  to  a  pul- 
monary cavity. 

This  sign  is  properly  a  variety  of  tympanitic  reso- 
nance. 


CRACKED-METAL    RESONANCE.  63 

6.  Cracked-metal  Resonance. 

The  name  of  this  sign,  expressing  an  analogy  to  the 
sound  produced  by  striking  a  cracked  metallic  vessel, 
denotes  its  peculiar  character.  It  may  be  imitated  by 
folding  the  hands  so  as  to  form  a  cavity  and  striking 
them  upon  the  knee,  in  the  familiar  trick  of  producing 
in  this  way  a  sound  as  if  metal  coins  were  between  the 
palms.  This  illustration,  also,  exemplifies  the  mecha- 
nism of  the  sign.  Like  the  sign  last  described,  it  is  a 
variety  of  tympanitic  resonance. 

The  cracked -metal,  like  the  amphoric,  resonance  rep- 
resents generally  a  phthisical  cavity.  Percussion  is  to 
be  made  in  the  same  way  as  for  the  production  of  the 
amphoric  resonance,  and,  like  the  latter,  the  cracked- 
metal  character  is  often  perceived  if  the  ear  be  brought 
close  to  the  patient's  mouth  when  otherwise  it  is  not  ap- 
preciable. 

The  cracked-metal  and  the  amphoric  resonance  are 
often  associated  ;  and  the  statements  made  with  respect 
to  the  exceptional  instances  in  which  the  latter  is  pro- 
duced, without  the  existence  of  a  pulmonary  cavity,  will 
apply  equally  to  the  former. 

In  addition  to  the  acoustic  phenomena  produced  by 
percussion  with  the  fingers  applied  to  the  chest  instead 
of  a  plexi meter,  an  abnormal  sense  of  r^esistance  is  felt  in 
certain  conditions  of  disease.  In  health,  with  a  some- 
what forcible  percussion,  the  walls  of  the  chest  are  felt 
to  yield  in  proportion  as  the  costal  cartilages  are  flexible. 
This  yielding  is  diminished  or  ceases  when  a  collection 
of  liquid  in  the  pleural  cavity,  or  liquid  in  the  air-vesicles, 
and  solidification  of  lung,  offer  a  mechanical  obstacle 


64  PERCUSSION    IN    DISEASE. 

thereto.  An  abnormal  sense  of  resistance  on  percussion, 
thus  determinable  by  comparison  of  the  two  sides  of  the 
chest,  is  a  sign  representing  some  one  of  the  morbid  phys- 
ical conditions  just  named.  This  properly  belongs  among 
the  signs  obtained  by  palpation.  The  sign  is  to  be 
taken  in  connection  with  other  signs  in  determining  the 
condition  which  exists  in  particular  cases. 


AUSCULTATION    IN    HEALTH.  65 


CHAPTER    IV. 

AUSCULTATION  IN  HEALTH. 

niportance  of  the  study  of  the  auscultatory  sounds  in  health — Imme- 
diate and  mediate  auscultation — Advantages  of  the  binaural  stetho- 
scope— Eules  to  be  observed  in  auscultation — Divisions  of  the  study 
of  auscultation  in  health — The  normal  laryngeal  and  tracheal  respi- 
ration— The  normal  vesicular  murmur ;  its  distinctive  character?, 
and  the  variations  in  the  different  regions  on  the  same  side,  and  in 
correspondingregionsonthe  two  sidesof  the  chest — The  normal  vocal 
resonance — The  laryngeal  and  tracheal  voice  and  whisper — Tlie  nor- 
mal thoracic  vocal  resonance  and  fremitus ;  the  distinctive  charac- 
ters of  each ;  the  variations  in  different  regions  on  the  same  side, 
and  in  corresponding  regions  on  the  two  sides  of  the  chest — The  nor- 
mal bronchial  whisper,  with  its  variations  in  diiferent  regions  on  the 
same  side,  and  in  corresponding  regions  on  the  two  sides  of  the  chest. 

The  terra  auscultation,  limited  in  its  application  to 
the  respiratory  system,  denotes  the  act  of  listening  to  the 
normal  and  abnormal  sounds  produced  by  respiration, 
voice,  and  cough.  In  this  and  the  next  chapter,  the 
method  of  exploration  thus  named  will  be  considered  in 
its  application  to  the  respiratory  system  ;  it  will  be  con- 
sidered subsequently,  as  applied  to  sounds  relating  to 
the  circulatory  system. 

The  study  of  auscultatory  sounds  in  health  is  essential 
as  preparatory  for  the  study  of  auscultation  in  disease. 
The  student  must  be  familiar  with  the  normal  sounds  be- 
fore undertaking  to  become  acquainted  with  those  which 
represent  morbid  conditions.  Ample  time  and  attention 
should  be  given  to  the  study  of  auscidtation  in  health. 
The  omission  to  do  this  is  a  frequent  cause  of  difBculty 


66  AUSCULTATION    IN    HEALTH. 

and  want  of  success  in  attaining  to  a  satisfactory  profi- 
ciency in  physical  diagnosis.  The  practical  tact  and 
skill  required  in  diagnosis  may  be  obtained  in  advance 
by  devoting  sufficient  study  to  the  healthy  chest  before 
entering  on  the  study  of  the  auscultatory  signs  of  disease. 
Moreover,  as  will  be  seen,  some  of  the  most  important 
morbid  signs  have  their  analogues  in  certain  normal 
sounds  pertaining  to  the  respiratory  system. 

Auscultation  is  either  immediate  or  mediate.  It  is 
immediate  when  the  ear  is  applied  directly  to  the  chest, 
which  may  be  either  denuded  or  covered  with  a  cloth  or 
more  or  less  of  the  clothing.  It  is  mediate  when  the 
sounds  are  conducted  to  the  ear  by  means  of  an  instru- 
ment called  a  stethoscope.  The  student  should  practice 
both  immediate  and  mediate  auscultation.  The  direct 
application  of  the  ear  to  the  chest  suffices  for  diagnosis 
in  many  cases  of  disease;  but  there  are  sometimes  ob- 
jections to  this  by  the  patient  on  the  score  of  delicacy, 
and  by  the  auscultator  on  the  score  of  the  uncleanliness 
of  the  person  examined.  There  are  certain  parts  of  the 
chest  which  can  only  be  explored  by  the  stethoscope,  and 
this  instrument  has  the  advantage  of  circumscribing  the 
space  whence  the  auscultatory  sounds  are  derived.  More- 
over, by  means  of  the  stethoscope  which  is  to  be  pre- 
ferred over  tiie  great  variety  of  instruments  heretofore 
in  use,  the  sounds  are  heard  much  better  than  by  imme- 
diate auscultation. 

The  stethoscope  which  is  to  be  preferred  conducts  the 
sounds  into  both  ears,  that  is,  it  is  binaural.  In  this  con- 
sists its  great  superiority.  At  tlie  present  time  wh;it  is 
known  as  Catnniann's  stethoscope^  seems  to  combine  more 
recommendations  than  any  otherformof  abinaural  instru- 

'  Invented  by  the  late  Dr.  Cauimunn,  of  New  York. 


AUSCULTATION    IN    HEALTH.  G7 

ment.  The  conduction  into  both  ears  renders  the  sounds 
much  louder  and  more  distinct  than  when  they  are  heard 
with  one  ear  in  either  mediate  or  immediate  auscultation. 
Another  advantage  is,  the  mind  is  not  distracted  by 
sounds  entering  the  ear  not  employed  in  auscultation. 
The  advantages,  however,  of  Canimann's  stethoscope  are 
not  appreciated  until  after  some  practice.  At  first,  a 
humming  sound  is  heard  which  divides  the  attention  and 
thus  obscures  the  intni-thoracic  sounds.  After  a  little 
practice  this  humming  sound  is  not  heeded,  and  it  ceases 
to  be  any  obstacle.  Many  wiio  use  the  instrument  only 
a  few  times  are  dissatisfied  with  it  and  discontinue  its 
use,  when,  if  they  had  used  it  longer,  they  would  not  have 
been  willing  to  dispense  with  it.  The  author's  experi- 
ence with  a  large  number  of  classes  in  private  instruc- 
tion has  been  this:  at  first,  most  members  of  a  class 
prefer  the  ear  applied  directly  to  the  chest;  but,  before 
the  course  of  instruction  is  ended,  the  binaural  stetho- 
scope is  so  much  ])referred  that  it  is  difficult  to  enforce  a 
fair  proportion  of  practice  in  inmiediate  auscultation. 

Another  reason  for  the  fact  that  this  stethoscope  is  not 
sufficiently  appreciated  in  this  country  is,  many  of  the 
instruments  sold  are  defectively  made.  Unless  proper 
attention  has  been  paid  to  all  the  nice  points  of  the 
stethoscope  as  devised  by  Cammann,  an  instrument  is 
worthless.  An  instrument  must  be  very  good,  or  it  is 
without  any  value.  The  knobs  which  are  to  enter  the 
ears  must  be  of  the  right  size  ;  if  they  enter  too  far  they 
occasion  ])ain.  The  curves  at  the  aural  extremity  must 
be  such  that  the  aperture  is  in  the  direction  of  the  meatus 
of  the  ear.  The  flexible  tubes  must  not  be  stiff,  and 
their  movements  must  be  noiseless.  All  the  tubes  must 
be  unobstructed,  for  it  is  the  air  within  the  tubes  which 


68  AUSCULTATION    IN    HEALTH. 

chiefly  conducts  the  sounds.  In  the  use  of  the  instru- 
ment it  should  be  applied  to  the  chest  without  any  inter- 
vening clothing.^ 

The  rules  to  be  observed  in  the  practice  of  ausculta- 
tion, in  health  and  disease,  may  be  here  introduced. 

In  auscultation,  as  in  percussion,  corresponding  situa- 
tions on  the  two  sides  of  the  chest  are  to  be  explored 
successively,  and  compared.  When  the  stethoscope  is 
used,  tliB  pectoral  extremity  must  be  applied  on  each  side 
with  the  same  degree  of  pressure;  this  is  especially 
essential  in  the  comparison  of  vocal  sounds.  In  imme- 
diate auscultation,  the  ear  is  to  be  applied  with  a  certain 
degree  of  force,  and  a  thin  layer  of  clothing  does  not 
interfere  materially  with  the  perception  of  auscultatory 
sounds.  The  ear  not  applied  to  the  chest  may  or  may 
not  be  closed  by  the  finger  in  listening  to  the  respira- 
tory sounds  ;  it  should  be  closed  in  listening  to  the  vocal 
sounds,  in  order  to  prevent  confusion  from  attention  to 
the  voice  from  the  patient's  mouth.  In  immediate  aus- 
cultation, whenever  practiced,  the  auscultator  should 
take  a  position  which  will  not  interfere  with  the  sense  of 
hearing,  and  not  occasion  a  feeling  of  discomfort.  These 
difficulties  are  in  the  way  of  auscultating  with  the  body 
bent  forward  ;  the  sense  of  hearing  is  dulled  by  the  de- 
tention of  blood  in  the  head,  and  the  position  cannot  be 
maintained  without  discomfort.  The  person  examined, 
if  practicable,  should  be  sitting,  and  the  position  for  the 
auscultator  is  that  of  kneeling  on  one  knee,  and  lower- 
ing, if  necessary,  the  body,  so  that  the  head  may  be  kept 
upright.  These  points  are  less  important  if  the  binaural 
stethoscope  be  used. 

^  The  stetlioscopes  made  by  Tieinann  &  ('o.  nnd   Ford  ik  Co.  are 
reliable. 


AUSCULTATION    IN    HEALTH.  69 

When  listening  to  respiratory  sounds,  it  is  generally 
desirable  that  the  person  examined  should  breathe  with 
somewhat  greater  fo  roe  than  in  ordinary  breathing;  but 
it  is  important  that  the  normal  rhythm  of  respiration 
should  be  unchanged.  Persons  when  requested  to  breathe 
with  increased  force  are  apt  to  err  in  breathing  violently, 
and  sometimes  too  slowly.  The  readiest  mode  of  obtain- 
inir  what  is  desired,  is  for  the  examiner  to  illustrate  it 
by  his  own  breathing.  A  complete  exi)iration  is  impor- 
tant in  order  to  secure  a  satisfactory  inspiration.  It 
should,  therefore,  be  made  clear  by  explanation  and 
illustration,  that  each  expiration  should  be  finished  be- 
fore the  following  inspiration.  Breathing  through  Dr. 
E.  Holden's  *' Resonator,"  a  flexible  tube  of  consider- 
able size,  with  a  mouth-piece,  secures  the  requisite  force 
of  the  resi)iratory  acts,  and  is  in  this  way  useful. 

The  ability  to  abstract  the  mind  from  thoughts  and 
other  sounds  than  those  to  which  the  attention  is  to  be 
directed,  is  essential  to  success  in  auscultation.  All  per- 
sons do  not  possess  equally  this  ability,  and  herein  is  an 
explanation  in  part  of  the  fact  that  all  are  not  alike  suc- 
cessful. To  develop  and  cultivate  by  practice  the  power 
of  concentration,  is  an  object  which  the  student  should 
keep  in  view.  Generally,  at  first,  complete  stillness  in 
the  room  is  indispensable  for  the  study  of  auscultatory 
sounds;  with  i)ractice,  however,  in  concentrating  the 
attention,  this  becomes  less  and  less  essential. 

The  study  of  auscultation  in  health  embraces  the  fol- 
lowing: 

1.  The  sounds  produced  by  respiration  as  heard  over 
the  larynx  and  trachea,  or  the  normal  laryngeal  and 
tracheal  respiration. 


70  AUSCULTATION    IN    HEALTH. 

2.  The  sounds  heard  over  the  chest  in  the  acts  of  res- 
piration. These  sounds,  coming  cliiefly  from  the  air- 
vesicles,  constitute  what  is  called  the  normal  vesicular 
murmur. 

3.  The  resonance  as  heard  over  the  chest,  and  the  vi- 
bration or  thrill  produced  by  the  loud  voice,  or  the  7ior- 
mal  vocal  resonance  and  fremitus. 

4.  The  sounds  as  heard  over  the  chest,  with  the  whis- 
pered voice,  or,  inasmuch  as  these  sounds  are  conducted 
chiefly  by  the  air  in  the  bronchial  tubes,  the  normal 
hroncldal  whisper. 

These  four  normal  signs  will  be  considered  in  the 
forego i no;  order. 

Normal  Laryngeal  and  Tracheal  Respiration. 

Forall  practical  purposes  the  laryngeal  and  the  tracheal 
respiration  may  be  considered  to  be  identical,  that  is,  the 
shades  of  difference  between  the  sounds  in  these  two  situ- 
ations are  not  of  importance  as  regards  the  application 
to  physical  diagnosis.  The  laryngeal  respiration  is  more 
readily  studied  than  the  traclieal,  and  for  the  study  of 
both  the  stethoscope  is  necessary. 

Applying  the  stethoscope  over  the  side  of  the  larynx, 
the  person  examined  breathing  with  some  increase  of 
force,  but  without  any  alteration  in  rhythm,  a  sound  is 
heard  with  each  of  the  two  acts  of  respiration.  The 
inspiratory  and  the  expiratory  sound,  studied  separately 
and  contrasted  with  each  other,  have  the  following  char- 
acters relating  to  intensity,  pitch,  quality,  duration,  and 
rhythm:  The  inspiratory  sound  is  of  variable  intensity. 
In  ordinary  breathing  it  varies  much  in  different  persons, 
and  in  different  acts  of  breathing  in  the  same  person. 
It  is   always  considerably  intense   in   forced  breathing. 


NORMAL    LARYNGEAL    RESPIRATION.  71 

The  pitch  is  high  when  compared  with  the  inspiratory 
sound  as  heard  over  the  chest.  The  quality  of  tlie 
sound  is  well  defined  by  the  word  tubular ;  the  sound  at 
once  suffsrests  a  current  of  air  through  a  tube.  Tlie 
duration  of  the  sound  is  from  the  beginning  to  nearly, 
not  quite,  the  end  of  the  inspiratory  act.  The  characters 
of  the  inspiratory  sound,  thus,  are  more  or  less  intensity, 
a  high  pitch,  a  tubular  quality,  and  a  duration  a  little  less 
than  that  of  the  act  of  inspiration. 

An  expiratory  sound  is  always  heard  with  forced 
breathing.  As  regards  duration,  it  is  as  long  as,  or 
longer  than,  the  sound  of  inspiration.  In  general  it  is 
more  intense  than  the  sound  of  inspiration.  The  pitch 
is  higher  than  that  of  the  inspiratory  sound.  The 
quality  is  the  same  as  that  of  the  inspiratory  sound, 
namely,  tubular. 

Repeating  the  characters  distinctive  of  the  normal 
laryngeal  respiration,  they  are  as  follows  :  The  inspira- 
tory sound  is  of  variable  intensity,  high  in  pitch,  and 
tubular  in  quality.  The  expiratory  sound  is  as  long  as, 
or  longer  than,  the  inspiratory  sound ;  it  is  higher  in 
})itch,  and  usually  more  intense.  Owing  to  the  ins})ira- 
tory  sound  not  continuing  quite  to  the  end  of  the  inspira- 
tory act,  there  is  a  very  short  interval  between  the  two 
sounds.  In  this  latter  point  consists  the  only  variation 
between  the  rhythm  of  the  acts  of  breathing  and  that  of 
the  sounds.  ^ 

The  foregoing  characters  should  not  only  be  verified 
by  the  student,  but  he  should  become  so  familiar  with 
them  by  practice  that  it  requires  no  effort  of  the  mind  to 
recollect  them.  It  will  be  seen  hereafter  that  these 
characters  of  the  normal  laryngeal  respiration  are  pre- 
cisely those  which  distinguish  an  important  morbid  phys- 
ical sign,  namely,  the  bronchial  or  tubular  respiration. 


72  AUSCULTATION    IN    HEALTH. 


Normal  Vesicular  Murmur. 

This  is  the  name  usually  given  to  the  respiratory 
sounds  heard  over  the  different  regions  of  the  chest. 
These  sounds  should  be  studied  with  the  ear  applied 
directly  to  the  chest  (immediate  auscultation),  as  well  as 
with  the  stethoscope.  In  commencing  the  study,  the 
middle  of  the  anterior  surface  of  the  chest  on  the  right 
side,  to  avoid  the  sounds  of  the  heart,  or  still  better, 
the  posterior  aspect  below  the  scapula  on  either  side, 
should  be  selected.  The  person  exaiuined  should  breathe 
somewhat  more  forcibly  than  in  ordinary  breathing,  but 
not  violently  nor  quickly,  nor  too  slowly,  the  normal 
rhythm  being  unchanged.  Children  are  better  than 
adults  for  this  study,  owing  to  the  greater  intensity  of 
the  murmur  in  early  life. 

The  characters  which  belong  to  the  inspiratory  and 
the  expiratory  sound  in  the  normal  vesicular  murmur 
are  as  follows  :  The  inspiratory  sound  is  of  variable  in- 
tensity. There  is  a  wide  variation  in  different  healthy 
persons.  In  some  persons  it  is  so  feeble  as  scarcely  to 
be  appreciable  even  with  the  binaural  stethoscope.  The 
pitch  of  the  sound,  compared  with  the  inspiratory  sound 
in  the  normal  laryngeal  or  tracheal  respiration,  is  nota- 
bly low.  The  quality  of  the  sound  is  peculiar;  no  dis- 
tinct idea  of  the  quality  can  be  formed  by  any  com- 
parison. The  name  used  to  designate  the  quality  is 
vesicular,  this  name  only  denoting  that  the  air-vesicles 
are  in  some  way  concerned  in  the  production  of  the  sound. 
This  vesicular  quality  must  be  impressed  upon  the  per- 
ception and  memory  by  direct  observation.  The  dura- 
tion of  the  inspiratory  sound  is  from  the  beginning  to 
the  end  of  the  inspiratory  act. 


NORMAL    VESICULAR    MURMUR.  73 

An  expiratory  sound  is  not  always,  altliongh  generally, 
appreciable.  It  is  much  less  intense  than  the  sound  of 
inspiration.  It  is  notably  lower  in  pitch  than  the  sound 
of  inspiration.  The  quality  of  the  sound  is  neither  vesicu- 
lar nor  tubular.  It  may  be  called  simply  a  blowing 
sound,  and  may  be  imitated  by  blowing  with  the  mouth 
partially  opened.  The  duration  is  much  shorter  than 
that  of  the  inspiratory  sound. 

The  characters,  thus,  which  distinguish  the  normal 
vesicular  murmur  are,  an  inspiratory  sound  variable  in 
intensity,  low  in  pitch,  and  vesicular  in  quality;  an  ex- 
piratory sound  less  intense  than  the  inspiratory,  still 
lower  in  pitch,  non-vesicular  and  non-tubular,  or  simply 
blowing;  the  inspiratory  sound  continuing  from  the  be- 
ginning to  the  end  of  the  inspiratory  act,  and  the  expira- 
tory sound  beginning  with  the  expiratory  act  but  ending 
before  this  act  is  completed,  its  duration,  relatively  to 
the  inspiratory  sound,  being  variable,  but  averaging 
about  a  fifth.  The  inspiratory  sound  continuing  to  the 
end  of  inspiration,  and  the  expiratory  sound  beginning 
with  the  act  of  expiration,  it  follows  that  there  is  no  in- 
terval between  the  two  sounds.  It  is  to  be  remarked 
that  an  interval  is  not  infrequently  produced  by  the  per- 
son examined  holding  the  breath  after  inspiration  is 
completed.  This  variation  in  the  rhythm  of  the  acts,  of 
course,  produces  a  corresponding  variation  in  sounds  of 
breathing. 

The  student  should  verify  these  characters,  compare 
them  with  the  characters  of  the  normal  laryngeal  respira- 
tion, and  become  practically  familiar  with  the  ditferen- 
tial  points.  He  should  then  proceed  to  study  the  normal 
vesicular  murmur  in  the  different  regions  of  the  chest. 
The  murmur  will  be  found  to  present  variations  in  the 


74  AUSCULTATION    IN    HEALTH. 

different  regions  on  the  same  side,  and  in  tlie  correspond- 
ing regions  on  the  two  sides  of  the  chest.  The  variations, 
within  the  range  of  health,  in  the  latter  are  especially 
important.  The  following  account  of  the  murmur  in  the 
different  regions  embodies  the  results  of  the  analysis  of 
a  series  of  recorded  examinations  of  healthy  persons. 

Right  and  Left  Infra  ■clavicular  Region. — The  mur- 
mur in  this  region,  on  either  side,  differs  more  or  less 
from  the  murmur  as  heard  in  the  anterior  regions  below, 
or  in  the  infra-scapular  region.  The  vesicular  quality 
in  the  inspiration  is  less  marked.  The  pitch  is  higher. 
The  expiratory  sound  is  longer,  less  feeble,  and  higher 
in  pitch.  The  difference  between  the  two  sides  in  this 
region  is  especially  important  with  reference  to  diagnosis. 
The  intensity  of  the  inspiratory  sound  is  almost  invaria- 
bly greater  on  the  left  side.  Its  vesicular  quality  is 
more  marked,  and  the  pitch  is  lower.  Per  contra,  the 
inspiratory  sound  on  the  right  side,  in  this  region,  is  less 
intense,  less  vesicular,  and  higher  in  pitch  than  the  in- 
spiratory sound  on  the  left  side.  In  forced  breathing 
the  intensity  of  the  murmur  is  increased  more  on  the 
left  than  on  the  right  side.  The  expiratory  sound  is 
sometimes  wanting  on  the  left,  when  it  is  heard  on  the 
right  side.  On  the  right  side,  the  expiratory  sound  is 
longer  than  on  the  left  side.  It  may  be  prolonged  on 
the  right  side  to  nearly  or  quite  the  length  of  the  inspi- 
ratory sound.  Sometimes  on  the  right  side  the  pitch  of 
the  expiratory  is  higher  than  that  of  the  inspiratory  on 
the  same  side,  and  it  may  have  a  tubular  quality.  A 
rare  peculiarity  is  a  prolonged,  higli,  tubular  expiratory 
sound  on  both  sides,  analogous  to  the  laryngeal  or  tra- 
cheal expiration.     When  this  is  the  case,  the  pitch  of 


NORMAL    VESICULAR    MURMUR.  75 

the  expiratory  sound  is  higher  on  the  left  than  on  the 
riocht  side. 

These  several  modifications  of  the  respiratory  murmur 
in  the  infra-clavicular  region  are  marked  in  proportion 
as  the  sounds  are  studied  near  the  sternum,  that  is,  over 
the  site  of  the  primary  bronchi.  The  respiratory  mur- 
mur in  this  situation  has  been  called  the  normal  bronchial 
respiration,  from  its  resemblance  to  the  morbid  sign  so 
named.  It  may  be  more  properly  called  a  vesiculo- 
tubular,  or  the  normal  broncho-vesicular  respiration,  the 
characters  beino;  those  of  the  morbid  sig-n  which,  under 
the  latter  name,  will  be  described  in  the  next  chapter. 

In  the  diagnosis  of  diseases,  especially  of  phthisis,  due 
allowance  must  be  made  for  the  points  of  disparity  which 
exist  normally  between  the  two  sides  of  the  chest  in  the 
infra-clavicular  region.  Without  a  practical  knowledge 
of  these  points  of  disparity^  error  in  diagnosis  can  hardly 
be  avoided. 

Rigid  and  Left  Scapular  Region. — As  compared  with 
the  infra-clavicular  region,  the  respiratory  murmur  heard 
over  the  scapula  on  either  side  is  feeble,  and  the  vesicu- 
lar quality  is  less  marked.  Tiie  inspiratory  sound  is 
generally  weaker  and  the  pitch  higher  on  the  right  than 
on  the  left  side.  Tiie  expiratory  sound  is  more  con- 
stantly heard  on  the  right  than  on  the  left  side.  It  may 
be  prolonged  on  the  right  side,  and  is  sometimes  higher 
in  pitch  than  the  inspiratory  sound.  Compared  with  the 
left  side,  the  murmur  on  the  right,  in  this  region,  thus 
may  have  vesiculo-tubular  or  broncho-vesicular  charac- 
ters more  or  less  marked. 

Right  and  Left  Lnter- scapular  Region. — In  tlie  upper 
and  middle  portions  of  this  region,  the  normal  characters 
are  the  same  as  in  the  sterno-clavicular  portion  of  infra- 


76  AUSCULTATION    IN    HEALTH. 

clavicular  region.  The  same  points  of  disparity  between 
the  two  sides  are  more  or  less  marked  here  as  they  are 
anteriorly  over  the  site  of  the  primary  bronchi. 

Right  and  Left  Infra-scapular  Region. — The  inten- 
sity of  the  murmur  is  greater  than  over  the  scapular 
region.  In  most  persons  there  is  no  notable  disparity 
between  the  two  sides  ;  when  a  disparity  exists,  the  in- 
tensity is  greater  and  the  pitch  lower  on  the  left  side. 
A  prolonged,  high-pitched,  bronchial  expiratory  sound 
is  sometimes  transmitted  below  the  scapula  on  the  right 
side. 

Right  and  Left  Mammary  and  Infra-mammary  Re- 
gions.— The  inspiratory  sound  in  these  regions  is  less 
intense  than  in  the  infra-clavicular  region  ;  the  vesicular 
quality  is  more  marked,  and  the  pitch  is  lower.  An  ex- 
piratory sound  is  often  wanting. 

Right  and  Left  Axillary  and  Infra-axillary  Regions. 
— The  inspiratory  sound  in  these  regions  is  as  intense 
as  in  any  portion  of  the  chest.  The  intensity  is  less  in 
the  infra-axillary  than  in  the  axillary  region,  and  the 
pitch  is  lower.  In  some  persons  the  murmur  on  the 
two  sides  presents  no  disparity,  but  in  other  persons  the 
vesicular  quality  is  somewhat  more  marked  and  the  pitch 
is  lower  on  the  left  than  on  the  right  side.  An  expira- 
tory sound  is  oftener  heard  than  in  the  mammary  and 
infra-mammary  regions. 

Normal  Vocal  Rescnance. 

Laryngeal  and  Tracheal  Voice. — It  will  prepare  the 
student  for  the  appreciation  of  the  distinctive  characters 
of  tlie  morbid  signs  pertaining  to  the  voice,  to  study  the 
vocal  signs  over  the  larynx  and  trachea.     Applying  the 


NORMAL    VOCAL    RESONANCE.  77 

stethoscope  either  over  the  broad  surface  of  the  thyroid 
cartilage,  or  just  abov^e  the  stenial  notch,  and  requesting 
the  person  examined  to  count  with  a  moderate  intensity 
of  voice,  the  auscultator  perceives  a  strong  resonance, 
with  a  sensation  of  concussion  or  shock,  and  a  sense  of 
vibration,  thrill,  or  fremitus.  The  voice  seems  to  be 
concentrated  and  near  the  ear.  Sometimes  the  articulated 
words  are  transmitted  so  as  to  be  heard  more  or  less  dis- 
tinctly. The  laryngeal  or  tracheal  voice,  thus  (laryn- 
gophony,  tracheophony)  embraces  different  elements, 
namely,  1st,  the  vocal  resonance;  2d,  the  concentration 
and  nearness  to  the  ear;  3d,  the  vibration,  thrill,  or 
fremitus ;  and  4th,  the  transmission  of  the  speech,  the 
latter  corresponding  to  pectoriloquy.  These  different 
elements  will  be  found  to  enter  into  the  distinctive  char- 
acters of  morbid  vocal  signs. 

The  sounds  heard  over  the  larynx  and  trachea  when 
words  are  spoken  in  a  w^hisper  should  bestudied,  inasmuch 
as  important  morbid  signs  relate  to  the  whispered  voice. 
Whispered  words  occasion  little  or  no  shock  or  thrill,  but 
an  intense,  high-pitched  tubular  sound,  with  a  sensation 
as  if  a  current  of  air  were  directed  into  the  ear  throuorh 
the  stethoscope.  This  sound  corresponds  to  the  sound 
of  expiration  in  laryngeal  or  tracheal  respiration;  the 
two  sounds  are,  in  fact,  identical  if,  as  is  the  case  with 
some  exceptions,  the  person  whisper  with  the  expiratory 
breath.  Articulated  words  are  transmitted  with  more 
or  less  distinctness,  thus  corresponding  with  the  morbid 
sign  called  whispering  pectoriloquy. 

Normal  Thoracic  Vocal  Resonance  and  Fremitus. — 
The  vocal  resonance  over  the  chest  is  to  be  studied  both 
by  means  of  the  stethoscope  and  by  immediate  ausculta- 
tion.    When  the  latter  is  employed,  the  car  not  applied 

7 


78  AUSCULTATION    IN    HEALTH. 

to  the  chest  should  be  closed,  in  order  to  exclude  the 
entrance  of  sound  from  the  mouth  of  the  person  exam- 
ined. When  the  stethoscope  is  employed,  care  must 
be  taken,  in  making  a  comparison  between  the  two  sides 
of  the  chest,  or  between  different  regions  on  the  same 
side,  that  the  pectoral  extremity  of  the  instrument  be 
pressed  \vith  an  equal  amount  of  force  against  the  chest. 
The  intensity  with  which  the  vocal  resonance  is  trans- 
mitted, is  much  affected  by  the  degree  of  pressure  with 
the  stethoscope. 

The  situations  in  which  the  student  should  commence 
the  study  of  the  normal  vocal  resonance  are  those  selected 
for  beginning  the  study  of  the  normal  vesicular  murmur, 
namely,  the  middle  of  the  anterior  aspect  of  the  chest  on 
the  right  side,  and  below  the  scapula  behind. 

With  the  stethoscope  or  the  ear  directly  applied  in 
the  situations  just  named,  the  person  examined  should 
be  requested  to  count  one,  two,  three,  in  a  uniform  tone, 
and  with  moderate  force.  The  examiner  should  himself 
pronounce  these  numerals,  in  order  to  show  the  manner 
of  counting.  This  is  far  better  than  asking  a  question 
and  studying  the  resonance  during  the  answer  of  the 
person  examined.  The  objection  to  the  latter  mode  is, 
the  attention  of  the  examiner  is  divided  between  the 
characters  of  the  thoracic  resonance  and  the  idea  con- 
veyed by  the  answer.  The  characters  of  the  vocal  reso- 
nance in  these  situations  are  as  follows : 

The  voice  is  heard  with  an  intensity  which  varies 
very  much  in  different  persons ;  in  some  the  resonance 
is  feeble,  and  it  may  be  almost  inappreciable,  while  in 
others  it  is  quite  intense.  The  intensity  depends  greatly 
on  the  loudness  and  lowness  in  pitch  of  the  voice  of  the 
person  examined.     The  resonance  is  notably  weaker  in 


NORMAL    VOCAL    RESONANCE.  79 

women  than  in  men.  It  is  rarely  attended  with  a  sense 
of  concussion  or  shock.  It  is  diffused;  tliat  is,  it  does 
not  seem  to  be  concentrated,  like  the  tracheal  or  laryn- 
geal vocal  resonance.  It  evidently  comes  from  a  certain 
distance;  that  is,  the  sound  does  .not  seem  to  be  near  the 
ear.  This  latter  character  is  distinctly  appreciable,  and 
is  highly  distinctive  of  the  normal  resonance  as  com- 
pared with  a  morbid  vocal  sign  (bronchophony).  The 
resonance  is  accompanied  by  a  sense  of  vibration,  thrill, 
or  fremitus,  the  intensity  of  which,  like  the  resonance, 
varies  much  in  diiferent  persons.  This  fremitus  is  prop- 
erly not  an  acoustic  but  a  tactile  sign.  The  normal  vocal 
fremitus,  together  with  its  abnormal  modifications,  be- 
longs to  the  method  of  physical  exploration  called  pal- 
pation. It  is,  however,  appreciated  by  the  ear  as  well 
as  by  the  touch,  and  may  be  studied  in  the  practice  of 
auscultation.  The  student  should  practically  distinguish 
from  each  other,  and  study  separately,  the  vocal  reso- 
nance and  vocal  fremitus. 

From  the  foregoing  characters  the  normal  vocal  reso- 
nance may  be  defined  as,  diffused,  distant,  variable  in 
intensity,  and  accompanied  with  more  or  less  vibration, 
thrill,  or  fremitus. 

Having  become  practically  familiar  with  these  char- 
acters of  the  normal  vocal  resonance  in  the  situations  in 
which  they  are  first  to  be  studied,  the  next  object  of 
study  relates  to  the  normal  variations  in  the  different 
regions  on  the  same  side  of  the  chest,  and  in  correspond- 
ing regions  on  the  two  sides.  In  giving  an  account  of 
these  variations,  based  on  a  series  of  recorded  examina- 
tions in  healthy  persons,  the  different  regions  will  be 
considered  in  the  same  order  as  in  the  study  of  the  vari- 
ations of  the  respiratory  sounds  (vide  p.  74  et  seq.). 


80  AUSCULTATION    IN    UEALTH. 

Infra-clavicular  Region. — The  vocal  resonance  in  this 
region  on  either  side  is  more  intense  than  in  the  anterior 
regions  below,  the  intensity,  however,  in  different  per- 
sons being  very  variable ;  irrespective  of  intensity,  it  is 
less  diffused,  nearer  the  ear,  and  the  pitch  is  somewhat 
higher.  These  latter  variations  are  marked  chiefly  in 
the  sterno-clavicular  extremity  of  the  region,  that  is, 
over  the  site  of  the  primary  bronchi.  In  some  persons 
the  concentration,  nearness  to  the  ear  and  elevation  of 
pitch,  especially  on  the  right  side,  are  such  as  to  approx- 
imate the  normal  resonance  to  the  morbid  sign  called 
bronchopliony.  The  characters  of  this  sign  will  be  con- 
sidered in  the  next  chapter,  but  it  is  important  to  know 
that  exceptionally  these  characters  may  be,  in  a  measure, 
illustrated  in  health  in  the  infra-clavicular  region.  The 
resonance  may  then  be  termed  normal  bronchophony. 

A  comparison  of  the  resonance  in  the  region  on  the 
right  and  on  the  left  side  always  shows  a  disparity.  The 
resonance  on  the  right  side  is  invariably  greater.  The 
degree  of  difference  between  the  two  sides  varies  in  dif- 
ferent persons.  The  resonance  may  be  more  or  less 
marked  on  the  right  and  nearly  wanting  on  the  leftside. 
Allowance  is  to  be  made  for  the  points  of  normal  dis- 
parity between  the  two  sides  in  the  diagnosis  of  disease; 
hence  the  student  must  become  practically  familiar  with 
them. 

The  vocal  vibration  or  fremitus  varies  fully  as  much 
as  the  vocal  resonance  in  different  persons.  Its  intensity 
is  not  always  proportionate  to  that  of  the  resonance  ;  that 
is,  the  resonance  may  be  com[)aratively  weak  when  the 
fremitus  is  strong,  and  vice-versa.  The  fremitus,  like  the 
resonance,  is  always  greater  on  the  right  than  on  the 


NORMAL    VOCAL    RESONANCE.  81 

left  side,  the  disparity,  like  that  of  the  resonance,  vary- 
ing; considerably  in  difl'erent  persons. 

Sca'pular  Region. — The  resonance  in  this  rei2:ion  is 
notably  less  intense  than  in  the  infra-clavicnlar  region. 
It  is  also  more  diffused  and  dis-tant.  The  intensity  is 
always  greater  on  the  right  side.  These  statements  are 
alike  ap[>licable  to  the  vocal  fremitus. 

Jntcr-^capular  Rajion. — The  intensity  of  the  reso- 
nance here  is  nearly  or  quite  as  great  as  in  the  sterno- 
clavicular extremity  of  the  infra-clavicular  region.  The 
resonance  has  in  some  |)ersons  in  this  region  the  charac- 
ters of  bronchophony.  The  intensity  is  always  greater 
on  the  right  sitle.  The  fremitus  is  more  or  less  marked, 
and  always  more  marked  on  the  right  than  on  the  left 
side. 

Infra-scapular  Region. — As  a  rule,  the  resonance  in 
this  region  is  stronger  than  over  the  scapula.  It  is 
always  characterized  by  diffusion  and  distance.  As  in 
all  the  regions,  it  varies  niuch  in  different  persons,  and 
is  stronger,  on  the  right  than  on  the  left  side.  These 
statements  are  also  applicable  to  fremitus. 

Mammary  and  Infra-mammary  Region>>. — The  reso- 
nance is  notably  less  than  at  the  summit  of  the  chest.  The 
characters  of  bronchophony  are  never  present.  The 
intensity  is  greater  on  the  right  side.  The  same  is  true 
of  fremitus. 

Axillary  and  Infra-axillary  Regions. — The  resonance 
in  these  regions,  and  especially  in  the  axillary  region,  is 
greater  than  over  the  mammary  and  infra-mammary  re- 
gions. It  is,  of  course,  stronger  on  the  right  side.  The 
characters  as  contrasted  with  those  of  bronchophony, 
namely,  distance  and  diffusion,  are  marked.     Fremitus 


82  AUSCULTATION    IN    HEALTH. 

is  more  or  less  marked,  and,  of  course,  more  marked  on 
the  right  than  on  the  left  side. 

Normal  Bronchial  Whisper. 

Prior  to  the  publication  of  the  author's  work  on  the 
"Physical  Exploration  of  the  Chest,"  in  1856,  signs  in 
heaUh  and  disease  relating  to  the  whispered  voice  had 
received  but  little  attention.  In  that  work,  and  more 
fully  in  the  second  edition,  published  in  1866,  a  series 
of  signs  accompanying  whispered  words  were  described 
and  named.  As  a  point  of  departure  for  the  study  of 
the  morbid  signs  thus  obtained,  of  course  the  signs  in 
health  must  first  be  studied.  The  sounds  which  are 
heard  over  different  parts  of  the  chest  in  health  I  have 
embraced  under  the  name,  the  normal  bronchial  whis- 
per. The  pertinency  of  this  name  is  derived  from  the 
fact  that  the  conduction  of  the  sound  produced  by  the 
whispered  voice  must  be  chiefly  by  the  air  contained  in 
tlie  bronchial  tubes.  The  sound  heard  over  the  trachea 
and  larynx  may  be  distinguished  as  the  laryngeal  or 
tracheal  whisper,  the  characters  of  which  have  been 
already  stated  (vide  page  77). 

It  will  facilitate  the  study  of  the  normal  bronchial 
whisper,  as  well  as  of  the  morbid  signs,  to  consider  that 
the  characters  of  the  sounds  produced  with  the  whispered 
voice  are  identical  with  those  produced  by  the  act  of 
expiration  in  all  respects  save  intensity.  Whispered 
words  are  produced,  as  a  rule,  by  an  act  of  expiration, 
the  sounds  being  more  intense  generally  than  those  which 
accompany  even  forced  breathing.  Curiously  enough, 
there  are  exceptions  to  this  rule.  Some  persons  insist 
upon  whispering  with  the  act  of  inspiration,  and  there 
are  some  persons  who  have  never  acquired  the  ability  to 


NORMAL    BRONCHIAL    WHISPER.  83 

whisper.  It  will  be  at  once  evident  that  the  pitch  and 
quality  of  sounds  produced  by  whispered  words  with 
the  act  of  expiration,  must  be  the  sanae  as  those  of  the 
sounds  of  expiration  in  breathing. 

Selecting  for  the  study  of  the  normal  bronchial 
whisper  the  same  situations  as  in  commencing  the 
study  of  the  normal  respiratory  murmur,  and  the  nor- 
mal vocal  resonance,  namely,  the  middle  of  the  chest  in 
front,  on  the  right  side,  and  the  infra-scapular  region  be- 
hind, with  the  whispered  voice  in  these  situations  is  heard, 
in  most  persons,  a  feeble,  low-pitched  blowing  sound, 
these  characters  corresponding  to  those  of  the  expiratory 
sound  in  forced  breathing.  The  normal  bronchial  whis- 
per in  these  situations  is  not  in  all  persons  appreciable. 

In  the  infra-clavicular  region,  the  bronchial  whisper  is 
heard,  with  variable  intensity,  in  most  persons.  It  is 
somewhat  higher  in  pitch  than  the  whisper  below  this 
reoion.  It  is  louder  and  hioher  in  the  sterno-clavicular 
than  in  the  acromial  extremity.  In  the  former  situation 
it  has  not  infrequently  a  tubular  quality.  It  is  louder 
on  the  right  than  on  the  left  side  of  the  chest.  It  is 
sometimes  heard  on  the  right  when  it  is  inappreciable  on 
the  left  side.  When  heard  on  both  sides  the  pitch  of  the 
sound  is  higher  on  the  left  than  on  the  right  side.  It 
will  be  observed  that  these  variations  correspond  to 
those  of  the  sound  with  expiration  in  the  infra-clavicu- 
lar region  [vide  page  75).  Occasionally  w' hispered  w^ords 
are  partly  transmitted,  constituting  incomplete  wdiisper- 
ing  pectoriloquy. 

In  the  scapular  region  the  bronchial  w^hisper  is  not 
infrequently  wanting.  It  may  be  present  on  the  right 
and  not  on  the  left  side,  and  if  present  on  both  sides,  it 
is  ahvays  louder  on  the  right  side. 


84  AUSCULTATION    IN    HEALTH. 

In  the  inter-scapular  region,  as  a  rule,  it  is  nearly  or 
quite  as  marked  as  over  the  site  of  the  primary  bronchi 
in  front.  The  pitch  is  more  or  less  high,  and  has  a 
tubular  quality.  It  is  louder  on  the  right  and  higher  in 
pitch  on  the  left  side,  and  in  this  situation  there  may  be 
incomplete  pectoriloquy. 

In  the  infra-scapular  region,  it  is  not  infrequently 
-wanting.  When  present  it  is  generally  feeble,  the  pitch 
being  low  and  the  quality  non-tubular  or  blowing.  It  is 
oftener  wanting  on  the  left  than  on  the  right  side,  and, 
if  present  on  both  sides,  it  is  louder  on  the  right  side. 

In  the  mammary  and  infra- mammary  regions  it  is  not 
infrequently  wanting,  and  the  statements  Just  made  with 
reference  to  the  infra-scapular  region  arealike  applicable 
to  these,  as,  also,  to  the  axillary  and  infra-axillary 
regions. 


AUSCULTATION    IN    DISEASE.  85 


CHAPTER   Y. 

AUSCULTATION  IX  DISEASE. 

The  respiratory  signs  of  Disease : — Abnormal  modifications  of  the  nor- 
mal respiratory  sounds  : — Increased  vesicular  murmur — Diminished 
vesicular  murmur  —  Suppressed  respiratory  sound — Bronchial  or 
tubular  respiration — Broncho-vesicular  respiration — Cavernous  res- 
piration— Broncho-cavernous  respiration — Vesiculo-cavernous  res- 
piration— Amphoric  respiration — Shortened  inspiration — Prolonged 
expiration — Interrupted  respiration.  Adventitious  respiratory 
sounds  or  rales:  Laryngeal  or  tracheal  rales — Moist  bronchial 
rales,  coarse,  fine,  and  subci'epitant — Vesicular  or  crepitant  rale — 
Cavernous  or  gurgling  rale — Pleural  friction  rales,  metallic  tink- 
ling and  splashing — Indeterminate  rales.  The  vocal  signs  of  dis- 
ease :  Bronchophony — Whispering  bronchophony — ^gophony — In- 
creased vocal  resonance — Increased  Bronchial  whisper — Cavernous 
whisper — Pectoriloquy — Amphoric  voice  or  echo — Diminished  and 
suppressed  vocal  resonance — Diminished  and  suppressed  vocal  fremi- 
tus—Metallic  tinkling.  Signs  obtained  by  acts  of  coughing  or  tus- 
sive signs. 

The  importance  of  becoming  perfectly  familiar  with 
the  signs  of  health  before  entering  upon  the  study  of  mor- 
bid signs,  cannot  be  too  strongly  enforced.  The  aus- 
cultatory signs  of  disease,  which  are  to  be  considered  in 
this  chapter,  should  not  be  studied  until  the  student  has 
made  himself  complete  master  of  all  the  characters  be- 
longing to  the  normal  signs  obtained  by  auscultation. 

Auscultation  in  disease  embraces  the  signs  produced 
by  respiration,  by  the  voice,  and  by  acts  of  coughing. 
The  respiratory  signs  will  be  first  considered. 

8 


86  AUSCULTATION    IN    DISEASE. 

The  Respiratory  Signs  of  Disease. 

The  signs  produced  by  respiration  may  be  classified 
as  follows :  1st.  Those  which  are  abnormal  modifica- 
tions of  the  normal  respiratory  sounds.  2d.  Those 
which  have  no  analogues  in  health,  being  entirely 
new  or  adv^entitious  sounds.  The  latter  are  embraced 
under  the  name  rale^. 

Abnormal  Modifications  of  the  Normal  Respiratory  Sounds. 

In  order  to  appreciate  the  distinctive  characters  of 
the  signs  embraced  in  this  class,  the  characters  which 
distinguish  the  normal  vesicular  murmur  must  be  kept 
in  mind.  The  abnormal  modifications  which  character- 
ize these  morbid  signs  relate  to  intensity,  pitch  and 
quality  of  sound,  together  with  certain  alterations  in 
rhythm.  Twelve  modifications  or  signs  are  included 
under  this  heading,  namely  :  1.  Increased  vesicular 
murmur;  2.  Diminished  vesicular  murmur;  3.  Suppres- 
sion of  respiratory  sound  ;  4.  Bronchial  or  tubular  res- 
piration ;  5.  Broncho-vesicular  respiration  ;  6.  Cavernous 
respiration  ;  7.  Broncho-cavernous  respiration  ;  8.  Ve- 
siculo-cavernous  respiration  ;  9.  Amphoric  respiration  ; 
10.  Shortened  inspiration;  11.  Prolonged  expiration; 
and,  12.  Interrupted  inspiration  or  expiration. 

These  signs  are  to  be  studied,  first,  with  reference  to 
their  distinctive  characters  severally,  each  being  con- 
trasted, as  respects  these  characters,  with  the  other  mor- 
bid respiratory  signs  as  well  as  with  the  normal  vesicu- 
lar murmur;  and,  second,  with  reference  to  the  morbid 
physical  conditions  which  they  represent,  that  is,  the 
diagnostic  significance  which  belongs  to  each. 


MODIFICATIONS    OF    NORMAL    SOUNDS.  87 


Increased  Yes'iGular  Murmur. — This  sign  has  but  a 
single  distinctive  character,  nanjely,  increase  of  intensity. 
The  murmur  is  abnormally  loud,  the  characters  of  the 
normal  vesicular  murmur  being  in  other  respects  not 
materially  changed,  that  is,  the  pitch  is  low  and  the 
quality  vesicular  as  in  health.  Now,  it  has  been  seen 
{vide  page  73)  that  the  intensity  of  the  healthy  murmur 
varies  much  in  diiferent  persons  ;  there  is  no  ideal  stand- 
ard of  normal  intensity  by  reference  to  which  an  abnor- 
mal increase  is  to  be  determined.  Yet  the  increase  under 
certain  conditions  of  disease  is  such  that  the  fact  is  suf- 
ficiently evident.  It  occurs  on  the  healthy  side  of  the 
chest  when  the  respiratory  function  on  the  other  side  is 
annulled  or  much  compromised  by  disease.  This  takes 
place  in  cases  of  pleurisy  with  large  effusion,  pneumonia, 
especially  if  more  than  one  lobe  be  affected,  obstruction 
of  one  of  the  primary  bronchi,  and  pneumothorax.  The 
sign  does  not  possess  great  diagnostic  importance,  inas- 
much as  the  nature  and  extent  of  the  disease  are  ascer- 
tained by  the  signs  obtained  on  the  affected  side. 

The  sign  has  been  called  supplementary  and  puerile 
respiration. 

If  the  murmur  be  much  intensified,  it  may  possibly  be 
mistaken  for  other  morbid  signs,  namely,  bronchial  or 
broncho-vesicular  respiration.  This  error,  howev^er,  can 
never  be  made  if  the  distinctive  characters  of  these  signs 
relating  to  pitch  and  quality  have  been  correctly  studied. 

Diminished  Vesicular  3Iurmur. — The  intensity  of  the 
vesicular  murmur  may  be  on  the  one  hand  diminished, 
when  it  is  evident  that  in  otiier  respects  there  is  no 
material  change,  and  the  murmur,  on  the  other  hand, 
may  become  so  feeble  that  characters  aside  from  the 
intensity  are  not  determinable.     From  the  latter  fact  it 


88  AUSCULTATION    IN    DISEASE. 

follows  that  the  murmur  must  sometimes  be  considered 
as  only  weakened,  when,  were  the  diminished  intensity 
not  as  great,  morbid  changes  in  pitch  and  quality  might 
be  appreciable. 

The  murmur  is  more  or  less  weakened  in  cases  of  dila- 
tation of  the  air-cells,  or  vesicular  emphysema,  the  sign, 
in  these  cases,  being  often  accompanied  by  changes  in 
rhythm,  namely,  a  shortened  inspiration  and  a  prolonged 
expiration.  Simple  weakness  of  the  murmur  may  also 
be  incident  to  partial  blocking  of  the  air-vesicles  with 
blood  or  serum  in  cases  of  j)iilmonary  extravasation  and 
oedema.  A  deficient  expansion  of  the  chest,  either  on 
one  side  or  on  both  sides,  occasions  weakness  of  the  re- 
spiratory murmur.  Deficient  expansion  of  one  side,  or  of 
both  sides,  may  be  caused  by  paralysis,  bilateral,  or 
unilateral,  of  the  costal  muscles.  A  similar  effect  is 
caused  by  paralysis  of  the  diaphragm.  The  incomplete 
descent  of  the  diaphragm  from  pain,  as  in  peritonitis,  or 
from  mechanical  obstacles,  as  in  peritoneal  dropsy,  preg- 
nancy, and  abdominal  tumors,  weakens  the  respiratory 
murmur,  the  increased  action  of  the  costal  muscles  not 
being  fully  compensatory.  Unilateral  deficiency  of  ex- 
pansion of  the  chest  is  caused  by  pain  in  intercostal  neu- 
ralgia, pleurodynia,  acute  pleurisy,  and  pneumonia;  it 
is  also  caused  by  the  presence  of  a  stratum  of  liquid,  air, 
or  a  thick  layer  of  lymph  between  the  lung  and  the  chest- 
wall  in  pleurisy,  hydrothorax,and  pneumothorax.  Swell- 
ing of  the  bronchial  mucous  membrane  in  bronchitis 
affecting  the  larger  tubes,  must  diminish  somewhat  the 
intensity  of  the  murmur.  In  primary  bronchitis  the 
murmur  is  diminished  on  both  sides.  In  bronchitis  affect, 
ing  the  smaller  tubes,  the  murmur  is  greatly  diminished, 
if  not  suppressed,  on  both  sides.    Incomplete  obstruction 


MODIFICATIONS    OF    NORMAL    SOUNDS.  89 

of  bronchial  tubes  from  the  presence  of  mucus,  serum, 
blood,  or  pus,  has  this  etfect  over  an  area  corresponding 
to  the  size  of  the  tubes  obstructed.  Spasm  of  the  bron- 
chial muscular  fibres  in  paroxysms  of  asthma,  diminishes, 
if  it  do  not  suppress,  murmur  on  both  sides.  Another 
cause  of  diminution,  unilateral,  or  within  a  limited  space 
on  one  side,  is  the  pressure  of  a  tumor  on  bronchial  tubes, 
as  in  cases  of  aneurism.  A  permanent  contraction  or 
stricture  of  bronchial  tubes  is  another  cause.  Not  in- 
frequently the  pressure  of  an  aneurismal  tumor  or  an 
enlarged  bronchial  gland  on  a  primary  bronchus,  occa- 
sions notable  weakness  of  the  murmur  over  the  whole  of 
one  side;  and  the  pressure  of  a  tumor  on  the  trachea 
weakens  the  murmur,  more  or  less,  on  both  sides.  A 
foreign  body  in  one  of  the  primary  bronchi  w^eakens  it 
on  one  side.  Diminution  of  the  calibre  of  the  trachea 
or  larynx  from  morbid  growths,  the  presence  of  foreign 
bodies,  fibrinous  exudations,  accumulations  of  mucus, 
submucous  infiltration,  spasms  of  the  laryngeal  muscles, 
and  swelling  of  the  mucous  membrane,  weakens,  in  pro- 
portion to  the  amount  of  obstruction,  the  murmur  on 
both  sides  Avithout  any  material  change  in  its  quality 
and  pitch. 

Weakened  murmur  at  the  summit  of  the  chest,  with- 
out other  appreciable- abnormal  characters,  occurs  in 
some  cases  of  phthisis,  due  to  obstructed  bronchial  tubes 
from  coexisting  circumscribed  bronchitis,  or  to  deficient 
superior  costal  movements  of  the  chest,  as  well  as  to  the 
presence  of  exudation  in  the  air-vesicles. 

Diminished  intensity  of  the  vesicular  murmur  is  thus 
seen  to  be  a  respiratory  sign  entering  into  the  diagnosis 
of  a  considerable  number  of  diseases,  namely,  emphy- 
sema, paralysis  affecting  the  respiratory  muscles,  asthma, 


90  AUSCULTATION    IN    DISEASE. 

abdominal  affections  interfering  with  the  diaphragmatic 
movements,  intercostal  neuralgia,  pneumonia,  hydro- 
thorax,  bronchitis,  aneurismal  and  other  tumors,  per- 
manent constriction  or  stricture  of  bronchial  tubes,  lar- 
yngitis, oedema  of  the  glottis,  spasm  of  the  glottis,  the 
various  lesions  which  occasion  obstruction  of  the  larynx 
or  trachea,  and  phthisis. 

In  determining  a  slight  abnormal  weakness  of  the  re- 
spiratory murmur  at  the  summit  of  the  chest  on  the  right 
side,  the  normal  disparity  between  the  two  sides  in  this 
situation  is  to  be  borne  in  mind.  The  vesicular  murmur 
is  normally  less  intense  on  the  right  than  on  the  left  side. 

This  sign  occurring  in  so  many  diseases,  it  is  obvious 
that,  taken  alone,  that  is,  independent  of  other  signs, 
it  has  not  any  special  diagnostic  significance.  It  is,  how- 
ever, often  of  value  in  diagnosis,  when  taken  in  connec- 
tion with  other  signs.  It  is  chiefly  useful  when  it  exists 
either  over  the  whole  or  in  a  part  of  the  chest  on  one 
side. 

Suppressed  Respiratory  Sound. — This  sign  is  easily 
defined,  namely,  absence  of  all  respiratory  sound,  as  the 
name  signifies.  It  cannot,  of  course,  have  any  charac- 
ters relating  to  intensity,  pitch,  and  quality. 

Su|)pression  of  respiratory  sound  represents  the  same 
physical  conditions  as  diminished  vesicular  murmur; 
the  physical  conditions  represented  by  the  latter  sign, 
existing  in  a  greater  degree,  occasion  absence  of  all 
sound.  It  suffices,  therefore,  to  recapitulate  the  various 
conditions  and  diseases  in  connection  with  which  the 
murmur  may  cither  be  diminished  or  suppressed.  Sup- 
pression over  portions  of  the  chest  may  be  due  to  dilata- 
tion of  the  air-cells  in  cases  of  emphysema.  It  occurs 
from  the  exclusion  of  air  from  the  vesicles  by  the  pros- 


MODIFICATIONS    OF    NORMAL    SOUNDS.  91 

ence  of  blood  and  serum  in  cases  of  pulmonary  extrav- 
asation and  cedema.  Respiratory  sound  is  sometimes 
wanting  over  lung  solidified  in  cases  of  pneumonia  and 
phthisis.  Paralysis  of  tiie  muscles  concerned  in  respira- 
tion may  possibly  involve  feebleness  of  the  respiratory 
acts  sufficiently  to  render  the  murmur  inappreciable.  In 
intercostal  neuralgia,  pleurodynia,  acute  pleurisy,  and 
pneumonia,  the  movements  of  the  affected  side  may  be 
so  much  restricted  as  to  abolish  the  murmur.  In  pleu- 
risy with  much  effusion,  empyema,  hydrothorax,  pneumo- 
thorax, the  murmur  is  suppressed  over  either  a  part  or 
the  whole  of  the  affected  side,  the  extent  of  the  suppres- 
sion corresponding  to  the  quantity  of  serum,  pus,  or  air 
within  the  pleural  cavity.  Swelling  of  the  mucous  mem- 
brane in  cases  of  bronchitis  affectino;  the  laro;er  bronchial 
tubes  is  never  sufficient  to  suppress  the  murmur,  but  plug- 
ging of  more  or  less  of  the  tubes  with  mucus  or  other 
morbid  products  may  have  this  effect.  In  cases  of  bron- 
chitis, the  murmur  is  sometimes  found  to  have  disap- 
peared over  a  certain  area,  and  to  return  after  an  act  of 
expectoration.  In  bronchitis  affecting  the  smaller  tubes, 
suppression  of  the  murmur  is  not  infrequent.  It  occurs 
from  spasm  of  the  bronchial  muscular  fibres  in  cases  of 
asthma.  The  pressure  of  a  tumor,  morbid  growths,  or 
deposits  upon  bronchi  within  the  lungs,  may  abolish  re- 
spiratory sound  over  a  portion  of  the  chest,  and  perma- 
nent stricture  or  obliteration  of  bronchial  tubes  may  have 
this  effect.  Respiratory  sound  may  be  suppressed  over 
the  whole  of  one  side  from  the  pressure  of  an  aneurismal 
or  some  other  tumor  upon  one  of  the  primary  bronchi. 
If  the  tumor  press  upon  the  trachea,  the  obstruction  may 
be  sufficient  to  suppress  the  murmur  on  both  sides.  A 
foreign  body  lodged  in  a  primary  bronchus  may  suppress 


92  AUSCULTATION    IN    DISEASE. 

the  murmur  on  one  side,  and,  lodged  in  the  larynx  or 
trachea,  the  murmur  may  be  suppressed  on  both  sides. 
The  different  affections  of  the  larynx  and  trachea  which, 
in  proportion  to  the  amount  of  obstruction,  weaken  the 
murmur,  may  render  it  inappreciable. 

Bronchial  or  Tubular  Respiration. — The  analogue  of 
this  sign  is  the  normal  laryngeal  or  tracheal  respiration 
{vide  page  70).  The  characters  which  distinguish  the 
latter  normal  sign  from  the  normal  vesicular  murmur,  are 
those  which  are  distinctive  of  the  bronchial  or  tubular 
respiration.  These  characters,  relating  to  the  inspiratory 
and  the  expiratory  sounds,  are  as  follows:  The  inspira- 
tory sound  is  of  variable  intensity.  Intensity  does  not 
enter  into  the  distinctive  characters  of  this  sign  ;  the 
sound  may  be  either  louder  or  weaker  than  the  inspira- 
tory sound  in  health.  The  })itch  of  the  inspiratory  sound 
is  high.  The  quality  is  expressed  by  the  term  tubular; 
it  is  like  the  sound  produced  by  blowing  through  a  tube, 
this  quality  taking  the  place  of  that  ex])ressed  by  the 
term  vesicular  in  the  normal  respiration.  The  expiratory 
sound  is  prolonged  ;  it  is  as  long  as,  or  longer  than,  the 
sound  of  expiration,  and  is*  usually  louder.  The  pitch 
is  still  higher  than  that  of  the  inspiratory  sound.  The 
quality,  like  that  of  the  inspiratory  sound,  is  tubular, 
thi.squality  taking  the  place  of  the  simple  blowing  quality 
of  the  expiratory  sound  in  the  normal  vesicular  murmur. 
With  the  normal  rhythm  of  the  respiratory  acts  there  is 
a  very  brief  interval  between  the  sounds  of  inspiration 
and  expiration,  due  to  the  fact  that  the  inspiratory  sound 
ends  a  little  before  the  end  of  the  inspiratory  act. 

The  morbid  physical  condition  represented  by  this  im- 
portant sign  is  either  complete  or  considerable  solidifica- 
tion of  lung.     Whenever  the  chest  is  auscultated  over 


MODIFICATIONS    OF    NORMAL    SOUNDS.  93 

lung  solidified,  if  there  be  not  absence  of  respiratory 
sound,  the  sound  is  tubular.  This  significance  renders 
the  sif^n  of  diagnostic  value  in  the  diseases  which  involve 
solidification.  The  sign  per  se  denotes  simply  this  mor- 
bid physical  condition  ;  the  particular  disease  which  ex- 
ists is  ascertained  by  means  of  the  associated  signs  and 
the  symptoms. 

Solidification  of  lung  is  incident  to  several  different 
diseases.  In  lobar  })neumonia  it  is  due  to  a  fibrinous 
exudation  within  the  air-vesicles.  In  phthisis  it  is  caused 
by  an  exudation  in  the  same  situation.  In  chronic  or 
fibroid  pneumonia  the  lung  is  solidified  by  an  interstitial 
growth.  The  compression  of  lung  from  either  pleuritic 
effusion,  an  accumulation  of  air  in  the  pleural  cavity,  or 
the  pressure  of  a  tumor,  causes  solidification  by  conden- 
sation. Collapse  of  pulmonary  lobules  also  solidifies  by 
condensation.  Coagulation  of  blood  within  the  air-vesi- 
cles (hsemorrhagic  infarctus),  and  cancerous  infiltration 
or  growth,  are  other  causes  of  solidification.  In  these 
different  affections,  if  the  solidification  be  complete  or 
considerable,  this  sign  is  usually  present;  it  is  always 
present  if  there  be  not  suppression  of  respiratory  sound. 

It  is  sometimes  the  case  that  either  the  inspiratory  or 
the  expiratory  sound  is  wanting.  The  characters  of  the 
sign  suffice  for  its  recognition  if  either  the  inspiratory  or 
the  ex[)iratory  sound  be  alone  present;  the  pitch  and 
the  quality  are  distinctive.  Both  sounds  are  often  so 
intense  that  they  are  diffused  more  or  less  without  the 
limits  of  the  solidified  portion  of  lung.  The  expiratory 
sound,  being  more  intense  than  the  inspiratory,  is  trans- 
mitted further  tlian  the  latter.  This  ex])lains  the  con- 
junction sometimes  of  a  vesicular  inspiration  with  a 
tubular  expiration  ;  and  a  cavernous  inspiration  may  be 


94  AUSCULTATION    IN    DISEASE. 

conjoined  with  a  tubular  expiration,  showing  the  prox- 
imity of  solidified  lung  in  the  former  case  to  healthy 
lung,  and,  in  the  latter  case,  to  a  pulmonary  cavity. 

The  sound  may  seem  near  the  ear  or  to  come  from  a 
certain  distance.  The  latter  is  appreciable  in  some  cases 
of  large  pleuritic  effusion  ;  the  tubular  respiration  is  more 
or  less  distant,  and  it  is  sometimes  diffused  over  the 
whole  of  the  side  which  is  filled  with  liquid. 

Broncho-vesicular  Respiration. — This  name  was  intro- 
duced by  me  in  185G  to  denote  the  combination,  in  vary- 
ing proportions,  of  the  characters  of  the  bronchial  or 
tubular,  and  of  the  normal  vesicular  respiration.  The 
name  expresses  such  a  combination.  It  embraces  modi- 
fications to  which  have  been  applied  the  terms,  rudcj 
rough,  and  harsh  respiration,  ajid  those  included  by  Ger- 
man authors  under  the  name  indeteiininate  respiratory 
sounds. 

The  sign  represents  the  different  degrees  of  solidifica- 
tion of  lung,  between  an  amount  so  slight  as  to  occasion 
only  the  smallest  appreciable  modification  of  the  respira- 
tory sound,  and  an  amount  so  great  as  to  approximate 
closely  to  the  degree  giving  rise  to  bronchial  or  tubular 
respiration.  In  other  words,  all  the  gradations  of  re- 
spiratory modifications,  caused  by  incomplete  or  an  in- 
considerable solidification,  which  fall  short  of  bronchial 
or  tubular  respiration,  are  embraced  under  the  name 
broncho-vesicular.  The  gradations  correspond  to  the 
amount  of  solidification,  that  is,  tlieyshow  the  solidifica- 
tion to  be  either  very  slight,  slight,  moderate,  or  nearly 
sufficient  to  be  considered  as  considerable  or  complete. 
The  sign  is  therefore  important  as  evidence,  first,  of  the 
existence  of  solidification,  and  second,  of  the  degree  of 
solidification. 


MODIFICATIONS    OF    NORMAL    SOUNDS.  95 

Analyzing  tliis  sign,  the  nnost  distinotive  feature  is  the 
combination  of  the  vesicular  and  the  tubular  quality  in 
the  inspiratory  sound.  These  two  qualities  niay  be 
combined  in  variable  proportions.  The  pitch  of  the 
sound  is  raised  in  proportion  as  the  tubular  predominates 
over  the  vesicular  quality.  The  expiratory  sound  is 
more  or  less  prolonged,  tubular  in  quality,  and  the  pitch 
is  raised.  The  prolongation  of  this  sound,  its  tubular 
quality,  and  the  highness  of  pitch,  are  proportionate  to 
the  predominance  of  the  tubular  over  the  vesicular 
quality  in  the  inspiratory  sound.  If  the  solidification  of 
luncr  be  slio^ht,  tlie  characters  of  the  normal  vesicular 
respiration  predominate  ;  that  is,  the  inspiratory  sound 
has  but  a  small  proportion  of  the  tubular  quality,  and  is 
but  little  raised  in  pitch,  the  expiratory  sound  being  not 
much  prolonged,  its  tubularity  not  marked,  the  pitch  not 
high.  If,  on  the  other  hand,  the  solidification  of  lung 
be  almost  enough  to  give  a  bronchial  respiration,  the 
inspiratory  sound  has  only  a  little  vesicular  quality,  the 
tubular  quality  ])redominating,  the  pitch  proportionately 
raised  ;  and  the  expiratory  sound  is  prolonged,  tubular, 
and  high,  nearly  to  the  same  extent  as  in  the  bronchial 
respiration.  The  less  the  solidification  the  more  the 
characters  of  the  normal  vesicular  predominate  over  those 
of  the  bronchial  respiration,  and,  per  contra,  the  greater 
the  solidification  the  more  the  characters  of  the  bronchial 
predominate  over  those  of  the  normal  vesicular  respira- 
tion. Daily  auscultation  in  a  case  of  lobar  pneumonia 
during  the  stage  of  resolution,  affords  an  opportunity  to 
study  all  the  gradations  of  this  sign.  After  resolution 
has  made  some  progress,  the  inspiratory  sound  is  no 
longer  ])urely  tubular,  but  the  ear  ap])reciates  a  little 
admixture  of  the  vesicular  quality,   and  the   pitch   is 


96  AUSCULTATION    IN    DISEASE. 

sliglitly  lowered.  As  resolution  goes  on,  the  vesicular 
quality  increases,  the  pitch  is  correspondingly  lowered, 
until,  at  length,  no  tubularity  remains,  and  the  pitch 
becomes  normal.  Meanwhile,  as  the  vesicular  quality 
increases  in  the  inspiratory  sound,  the  expiratory  sound 
is  less  and  less  prolonged,  high  and  tubular,  until  it  be- 
comes, as  in  health,  short,  low,  and  blowing. 

The  broncho-vesicular  respiration  is  an  important 
diagnostic  sign  in  all  the  affections  which  involve  partial 
solidification  of  lung.  In  lobar  pneumonia,  as  just  stated, 
it  denotes  the  progress  made  from  day  to  day  in  resolu- 
tion. It  is  found  also  in  an  earlier  stage,  before  the 
solidification  is  sufficient  to  give  rise  to  a  purely  bron- 
chial respiration.  It  is  a  valuable  sign  in  phthisis,  afford- 
ing evidence,  not  only  of  the  fact  of  solidification,  but 
of  its  degree  and  extent.  The  sign  enters  into  the  diag- 
nosis of  interstitial  pneumonia,  hsemorrhaglc  infarctus, 
condensation  of  lung  from  the  pressure  of  either  liquid, 
air,  or  a  tumor,  and  from  collapse  of  pulmonary  lobules. 
It  may  be  stated  with  respect  to  this  sign,  that  it  is 
always  present  if  the  lung  be  partially  solidified,  pro- 
vided there  be  not  either  suppression  of  respiratory 
sound,  or  such  a  degree  of  feebleness  that  the  distinctive 
characters  are  undeterminable.  As  with  the  bronchial 
respiration,  so  with  the  broncho-vesicular,  either  the  in- 
spiratory or  the  expiratory  sound  may  be  wanting.  The 
characters  of  the  sign  are  then  to  be  determined  as  they 
are  manifested  in  the  sound  which  is  present,  namely, 
the  combination  of  the  vesicular  and  the  tubular  (juality, 
with  more  or  less  elevation  of  pitch,  if  only  an  insj)ira- 
tory  sound  may  be  heard,  and  the  amount  of  prolonga- 
tion, tubularity,  and  elevation  of  pitch,  if  there  be  only 
an  expiratory  sound. 


MODIFICATIONS    OP    NORMAL    SOUNDS.  97 

In  deteriiiininf^  the  presence  of  this  morbid  sign,  at 
tlie  summit  of  tlie  chest  on  the  right  side,  it  is  to  be 
borne  in  mind  that  the  respiratory  murmur  on  this  side 
has,  in  health,  as  compared  with  the  res})iratory  murmur 
at  tlie  summit  on  the  left  side,  more  or  less  of  the  char- 
acters of  the  broncho-vesicular  respiration  (^Me  Normal 
Broncho- vesicular  Respiration,  page  94). 

Caver-nous  Respiration. — The  modifications  which  con- 
stitute the  distinctive  characters  of  this  sign,  are  ])roduccd 
by  the  entrance  of  air  into  a  cavity  with  the  act  of  inspi- 
ration, and  its  exit  from  the  cavity  with  the  act  of  expi- 
ration. This  passage  of  air  into  and  from  a  cavity  can 
only  take  place  where  the  walls  of  the  cavity  collapse 
more  or  less  in  expiration  and  exj)and  in  inspiration. 
Pulmonary  cavities  occur  chiefly  in  cases  of  phthisis. 
They  occur,  but  with  com|)arative  infrecpiency,  as  a  re- 
sult of  circumscribed  abscess  and  gangrene  of  lung. 

A  well-marked  cavernous  respiration  has  characters 
which  are  highly  distinctive  when  this  sign  is  contrasted, 
on  the  one  hand,  with  either  the  bronchial  or  broncho- 
vesicular  respiration,  and,  on  the  other  hand,  with  the 
normal  vesicular  murmur.  These  distinctive  characters 
relate  both  to  the  inspiratory  and  expiratory  sound. 
The  inspiratory  sound  is  neither  vesicular  nor  tubular  in 
quality,  and  the  pitch  is  low  as  compared  with  the  bron- 
chial respiration.  As  regards  quality,  we  may  say  of  it, 
as  of  the  expiratory  sound  in  the  normal  vesicular  respi- 
ration, it  is  simply  a  blowing  sound.  The  expiratory 
sound  has  the  same  quality  as  the  inspiratory,  and  it  is 
lower  in  pitch.  Its  duration  is  variable.  The  intensity 
of  both  the  inspiratory  and  the  expiratory  sound  varies; 
intensity  does  not  enter  into  the  distinctive  characters  of 
this  sign  more  than  into  those  of  the  bronchial  and  the 


98  AUSCULTATION    IN    DISEASE. 

broncho-vesicular  respiration.  These  distinctive  char- 
acters of  the  cavernous  respiration,  as  regards  pitch  and 
quality,  especially  of  the  expiratory  sound,  were  first 
pointed  out  by  me  in  1852.^  Prior  to  this  date  the 
bronchial  and  the  cavernous  respiration  were  considered 
as  having  identical  characters,  or,  at  all  events,  as  not 
distinguishable  from  each  other.  Following  Skoda, 
these  two  signs  are  still  considered  as  essentially  identi- 
cal by  German  authors.  With  a  practical  knowledge 
of  the  foregoing  characters  distinctive  of  the  cavernous 
respiration,  there  is  no  difficulty  in  discriminating  this 
sign  from  the  bronchial  respiration.  The  sign  is  more 
likely  to  be  confounded  with  the  normal  vesicular  mur- 
mur, inasmuch  as  it  differs  from  the  latter  only  in  the 
absence  in  the  inspiratory  sound  of  the  vesicular  quality. 
Against  this  error  the  student  is  to  be  cautioned.  It  is 
most  likely  to  be  made  when  the  inspiratory  sound  is 
much  weakened,  and,  consequently,  the  vesicular  quality 
less  distinctly  appreciable  than  when  the  sound  is  more 
or  less  intense. 

A  cavernous  respiration  is  limited  to  a  space  more  or 
less  circumscribed,  the  area  corresponding  to  the  site  and 
the  size  of  the  cavity.  Occurring,  for  the  most  part,  in 
cases  of  phthisis,  it  is  much  oftener  found  at  the  summit 
than  elsewhere  over  the  chest.  It  is  not  constantly  found 
where  there  is  a  cavity  witii  flaccid  walls.  It  may  be 
temporarily  suppressed  by  the  presence  of  liquid  within 
the  cavity,  and  by  obstruction  of  the  orifices  communi- 
cating with  bronchial  tubes,  or  of  the  latter.  It  may  be 
wanting  at  one  moment,  and  an  act  of  expectoration  may 

1  Prize  Essay  on  Variations  of  Pitch  in  tlie  Sounds  obtained  by 
Percussion  and  Au-;cultation.  Transactions  of  the  American  Medi- 
cal Association,  1852. 


MODIFICATIONS    OF    NORMAL    SOUNDS.  99 

cause  it  to  reappear.  Hence  absence  of  cavity  cannot 
be  predicated  on  the  absence  of  tlie  sign  at  a  single  ex- 
amination. Moreover,  if  a  cavity  be  not  situated  near 
the  pulmonary  superficies,  and  solidified  lung  intervene 
between  it  and  the  walls  of  the  chest,  the  cavernous  sign 
may  be  drowned  in  a  loud  bronchial  respiration.  For 
this  reason,  while  the  cavernous  sign  is  positive  evi- 
dence of  a  cavity,  the  absence  of  the  sign  is  not  proof 
that  a  cavitv  does  not  exist. 

In  some  cases  of  perforation  of  lung  with  pneumo- 
thorax, the  passage  of  air  to  and  fro  through  the  perfor- 
ation may  give  rise  to  the  cavernous  respiration.  As  a 
rule,  however,  under  these  circumstances,  another  sign  is 
produced,  namely,  the  amphoric  respiration. 

Broncho -cavernous  Respiration. — In  this  sign,  as  the 
name  denotes,  the  characters  of  the  bronchial  and  the 
cavernous  respiration  are  combined.  These  characters 
may  be  combined  in  different  ways,  as  w^ell  as  in  varia- 
ble proportions.  If  a  cavity  be  situated  in  proximity  to 
solidified  lung,  the  quality  and  pitch  of  the  inspiratory 
and  the  expiratory  sound  may  show  an  admixture  of  the 
characters  of  the  two  signs,  and  to  a  practiced  ear,  the 
combination  is  distinctly  recognizable.  This  is  one  of 
the  forms  of  broncho-cavernous  respiration  ;  the  sounds 
are  not  sufficiently  high  and  tubular  for  bronchial,  nor 
sufficiently  low  and  blowing  for  cavernous  respiration. 
Another  form  consists  of  an  inspiratory  sound,  the  first 
part  of  which  is  tubular,  and  the  latter  part  cavernous. 
Examples  of  this  form  are  not  extremely  infrequent. 
This  form  has  been  recently  described  by  Seitz  under 
the  name,  "  metamorphosing  respiration.''^  Still  another 
form  is  a  cavernous  inspiratory,  with  a  bronchial  or 
tubular  expiratory  sound.     In  the  latter  form,  the  bron- 


100  AUSCULTATION    IN    DISEASE. 

chial  expiration  proceeds  from  solidified  lung  situated 
near  tlie  cavity,  the  intensity  of  the  sound  being  suffi- 
cient to  drown  the  cavernous  expiration. 

When,  as  often  happens,  a  cavity  is  situated  in  close 
proximity  to,  or,  it  may  be,  surrounded  by  solidified 
lung,  the  cavernous  and  the  bronchial  respiration  are,  as 
it  were,  in  juxtaposition,  and  such  instances  offer  an 
excellent  opportunity  to  study  the  points  distinguishing 
these  signs  from  each  other;  and,  generally,  at  a  short 
distance  the  normal  vesicular  murmur  may  be  found,  so 
that  both  morbid  signs  may  be  compared  with  the  latter. 
Within  a  circumscribed  area,  sometimes,  are  exemplified 
the  characters  of  the  normal  murmur,  and  of  the  two 
morbid  signs  just  mentioned,  together  with  those  of  the 
broncho- vesicular  respiration. 

Vesiculo- cavernous  Respiration. — It  is  sometimes  evi- 
dent that  the  vesicular  and  the  cavernous  quality  are 
combined  in  the  inspiratory  sound.  This  occurs  when  a 
cavity  is  surrounded,  not  by  solidified,  but  by  healthy 
lung.  Under  these  circumstances,  over  the  site  of  the 
cavity,  the  inspiratory  sound  may  be  as  loud  as,  or  louder 
than  that  around  the  cavity,  but  the  quality  is  not  purely 
cavernous;  some  vesicular  quality  is  appreciable.  A 
vesiculo-cavernous  respiration,  then,  is  a  cavernous  res- 
piration plus  some  vesicular  quality  derived  from  the  air- 
vesicles  which  are  proximate  to  the  cavity.  This  sign  is 
corroborated  by  other  associated  signs  showing  the  ex- 
istence of  a  cavity  and  its  localization. 

Amphorie  Respiration. — The  term  amphoric  has  a 
significance  when  applied  to  auscultatory  sounds,  analo- 
gous to  that  which  it  has  in  percussion  ;  it  denotes  a 
musical  intonation  which  may  be  compared  to  the  sound 
produced  by  blowing  upon  the  open  mouth  of  a  decanter 


MODIFICATIONS    OP    NORMAL    SOUNDS.  101 

or  pliial.  Whenever  the  respiratory  sound  has  this  in- 
tonation, it  denotes  a  space  containing  air  which  is  not 
expelled  with  the  act  of  expiration.  Air  in  the  pleural 
cavity,  with  perforation  of  hin^,  is  the  physical  condition 
most  frequently  represented  by  this  sign.  It  is  a  valu- 
able diagnostic  sign  in  cases  of  pneumothorax ;  but  it  is 
not  always  present  in  that  affection,  certain  accessory 
conditions  being  requisite,  namely,  perforation  above  the 
level  of  liquid,  and  an  unobstructed  communication  of 
the  bronchial  tubes,  through  the  opening,  with  the  pleu- 
ral space  containing  air.  While,  therefore,  its  presence  is 
significant  of  pneumothorax,  its  absence  is  by  no  means 
sufficient  to  exclude  this  affection.  Not  infrequently,  it 
is  a  sign  of  phthisical  cavity  with  rigid  walls  which  do 
not  collapse  with  the  act  of  expiration.  The  same  con- 
tingencies affect  its  production  here  as  in  cases  of  pneu- 
mothorax. Whenever  amphoric  respiration  is  present, 
if  pneumothorax  be  excluded  by  the  absence  of  the  other 
signs  which  are  diagnostic  of  this  affection,  the  sign  is 
proof  of  the  existence  of  a  pulmonary  cavity,  the  walls 
of  which  aie  not  flaccid.  The  sign  then  takes  the  place 
of  the  ordinary  cavernous  respiration  which  has  been 
described. 

The  amphoric  sound  may  accompany  either  respira- 
tion or  expiration,  or  both. 

Slwrtened  Inspiration.  —  The  inspiratory  sound  is 
somewhat  shortened  in  bronchial  or  tubular  respiration. 
This  modification  enters  into  the  characters  of  that  sign, 
the  quality  of  the  sound  being  tubular;,  and  the  pitch  high. 
The  shortening  is  due  to  the  sound  ending  before  the 
inspiratory  act  ends ;  the  sound  is  said  to  be  unfinished. 
Shortening  of  the  sound  occurs,  however,  when  it  is  not 
an  element  in  the  bronchial  respiration.     The  shortening 

9 


102  AlfSCULTATION    IN    DISEASE. 

is  then  due  to  tlie  sound  not  beginning  with  the  inspira- 
tory act;  this  is  distinguished  as  deferred  inspiratory 
sound.  A  deferred  inspiratory  sound  not  tubular  in 
quality,  but  more  or  less  vesicular,  and  not  notably  raised 
in  pitch,  is  a  sign  of  pulmonary  or  vesicular  emphysema. 
It  is  a  sign  of  value  in  connection  with  the  diagnosis  of 
that  disease. 

The  student  should  note  the  distinctions  just  stated 
which  relate  to  pitch  and  quality.  Suppose  an  inspira- 
tory sound  to  be  present  without  an  expiratory  sound: 
if  the  sound  be  shortened  at  the  end  of  the  inspiration, 
the  pitch  high  and  the  quality  tubular,  it  is  bronchial 
respiration,  denoting  complete  or  considerable  solidifica- 
tion of  lung,  but  if  the  shortening  be  at  the  beginning  of 
respiration,  the  pitch  comparatively  low,  and  vesicular 
quality  be  appreciable,  the  sign  denotes  emphysema.  The 
differential  points  thus  are,  the  inspiratory  sound  either 
unfinished  or  deferred,  the  pitch  either  high  or  low,  and 
the  quality  either  tubular  or  vesicular.  Attention  to  these 
points  is  essential  in  order  to  avoid  error  in  the  interpre- 
tation of  the  sign. 

Prolonged  Expiration. — The  length  of  the  expiratory 
sound  in  health  varies  in  different  persons.  The  sound 
is  sometimes  considerably  prolonged ;  it  may  be  nearly 
as  long  as  the  sound  of  inspiration.  There  is  no  diffi- 
culty in  recognizing  this  as  a  normal  peculiarity,  from  the 
fact  that  the  murmur  has  the  pitch  and  quality  of  health. 
An  unusual  length  of  the  expiratory  sound,  within  the 
range  of  health,  is  usually  observed  at  the  summit  of  the 
chest,  and  especially  on  the  right  side.  It  is  important 
to  bear  in  mind  that  at  the  summit  of  the  chest  on  the 
right  side,  and  sometimes  also  on  the  left  side,  a  pro- 
longed expiratory  sound,  more  or  less  raised  in  pitch,  and 
tubular  in  quality,  may  be  a  normal  peculiarity.     It  fol- 


MODIFICATIONS    OF    NORMAL    SOUNDS.  103 

lows  that  a  prolonged,  and  even  a  high  and  tubular  ex- 
piration at  the  summit  of  the  chest,  must  not  be  reckoned 
as  a  morbid  sign  unless  it  be  associated  with  other  signs 
denoting  disease.  The  laws  of  the  disparity  between  the 
two  sides  of  the  chest  at  the  summit  are  to  be  taken  into 
account  {vide  p.  74).  If  the  expiration  be  longer  on 
the  left  than  on  the  right  side^  it  is  abnormal ;  so,  also, 
is  a  high-pitched  tubular  expiration  heard  on  the  left  and 
not  on  the  right  side. 

The  significance  of  an  abnormally  prolonged  expira- 
tion depends  on  its  pitch  and  quality.  If  it  be  high  and 
tubular,  it  denotes  solidification  of  lung.  It  is,  in  fact, 
bronchial  respiration.  As  already  stated,  in  bronchial 
or  tubular  respiration,  the  inspiratory  sound  is  some- 
times wanting,  and  the  presence  of  the  sign  is  then  to  be 
determined  by  the  characters,  relating  to  pitch  and  qual- 
ity, of  the  expiratory  sound.  The  same  statement  holds 
true  with  respect  to  broncho-vesicular  respiration,  when 
this  approximates  to  the  bronchial.  At  the  summit  of 
the  chest,  the  characters  of  the  inspiratory  sound,  and 
associated  morbid  signs,  always  enable  the  auscultator  to 
determine  whether  a  prolonged  high  and  tubular  expira- 
tion be,  or  be  not,  abnormal.  A  prolonged  expiration, 
which  is  low  in  pitch  and  blowing  in  quality,  that  is, 
with  the  characters  of  health,  aside  from  length,  may 
belong  to  a  cavernous  expiration.  This  is  to  be  deter- 
mined by  the  characters  of  the  inspiration,  and  by  other 
associated  signs.  Exclusive  of  cavernous  respiration,  an 
abnormally  prolonged  expiratory  sound  of  low  pitch  and 
non-tubular,  denotes  vesicular  emphysema.  It  is  asso- 
ciated then  with  a  weakened  and  deferred  inspiratory 
sound.  A  prolonged  expiratory  sound,  in  cases  of  emphy- 
sema, is  invariably  low  and  non-tubular.     If  it  have 


104  AUSCULTATION    IN    DISEASE. 

not  these  characters,  it  is  not  a  sign  of  emphysema,  but 
belongs  to  bronchial  or  broncho-vesicular  respiration. 
Attention  to  these  differential  points  is  to  be  enjoined 
upon  the  student. 

A  prolonged  expii'ation  at  the  summit  of  the  chest  on 
the  right  side  is  sometimes  incorrectly  considered  to  be 
evidence  of  phthisis.  It  is  to  be  recollected,  in  the  first 
place,  that  prolongation  of  this  sound  with  a  normal 
pitch  and  quality,  is  never  evidence  of  solidification  of 
lung  either  from  phthisis  or  any  other  disease;  and  in 
the  second  place,  even  if  the  pitch  be  high,  and  the  qual- 
ity tubular,  that  it  is  not  to  be  regarded  as  abnormal, 
provided  the  inspiratory  sound  is  unchanged,  and  other 
signs  of  disease  are  not  present.  At  times  in  bronchitis 
there  is  a  prolonged  expiratory  sound  which  may  be  dis- 
tinguished as  a  sonorous  expiration,  not  amounting  to  a 
rale.  This  is  liable  to  be  mistaken  for  broncho-vesicu- 
lar breathing. 

Interrupted  Respiration. — To  this  sign  have  been  ap- 
plied other  names,  such  as  jerking^  wavy,  cogged  icheel, 
and  by  French  writers  the  names  entrecoupee  and  sacca- 
dee.  The  modification  is  either  of  the  inspiration  or  of 
the  expiration,  or  of  both.  The  inspiratory,  however, 
much  more  frequently  than  the  expiratory,  sound  is  in- 
terrupted. Tlie  sound,  instead  of  being  continuous,  is 
broken  into  one,  two,  or  more  parts.  This  is  the  char- 
acteristic of  the  sign.  If  at  the  same  time  there  be  altera- 
tions in  pitch  and  quality,  the  interruption  is  merely 
incidental  to  other  signs  ;  namely,  the  bronchial,  broncho- 
vesicular,  or  cavernous  respiration.  To  constitute  it  a 
distinct  sign,  the  interruption  must  be  the  only  appreci- 
able change.  As  a  distinct  sign  it  has  but  little  diag- 
nostic value. 


MODIFICATIONS    OF    NORMAL    SOUNDS.  105 

Interrupted  respiration  is  sometimes  found  in  healthy 
persons.  It  is  confined  to  the  summit  of  the  chest,  and 
oftener  on  the  left  tiian  the  right  side.  Existing  without 
anv  other  signs,  therefore,  it  is  not  evidence  of  disease. 
It  is  of  value  only  in  the  diagnosis  of  phthisis.  Associ- 
ated with  other  signs,  when  the  latter  are  not  marked,  it 
is  entitled  to  a  certain  amount  of  weight  in  the  diagnosis. 

Interrupted  respiratory  sounds,  of  course,  occur  when 
there  is  interruption  in  the  respiratory  movements.  This 
happens  in  cases  of  pleurisy,  pleurodynia,  or  intercostal 
neuralgia.  Owing  to  the  pain  caused  by  the  movements 
in  respiration,  the  })atient  may  breathe,  not  continuously, 
but  with  a  series  of  jerking  movements.  Sometimes  in- 
terrupted breathing  is  observed  in  persons  who  are  ex- 
cited or  agitated  when  auscultation  is  practiced.  In  all 
these  instances,  interruption  in  the  respiratory  sounds  is 
found  over  the  ^vliole  chest,  whereas,  when  it  is  an  ab- 
normal sign  in  cases  of  phthisis,  it  is  limited  to  the  sum- 
mit on  one  side  of  the  chest,  and  there  is  no  interruption 
manifested  in  the  mode  of  breathing. 

Reviewing  the  foregoing  signs,  they  may  be  distributed 
into  three  classes,  as  ibllows  :  1st.  Signs,  the  distinctive 
characters  of  which  relate  to  either  the  absence  or  the 
intensity  of  sound.  This  class  embraces,  (a)  increased 
intensity  of  the  vesicular  murmur;  (b)  diminished  in- 
tensity of  the  vesicular  murmur;  and  (c)  suppression  of 
respiratory  sound.  2d.  Signs,  the  distinctive  characters 
of  which  relate  especially  to  pitch  and  quality.  In  this 
class  belong,  (a)  bronchial  or  tubular  respiration  ;  (b) 
broncho-vesicular  respiration  ;  (c)  cavernous  respiration; 
(d)  broncho-cavernous  respiration  ;  (e)  vesiculo-cavern- 
ous   respiration,    and    (f)   amphoric    respiration.      3d. 


106  AUSCULTATION    IN    DISEASE. 

Signs,  the  distinctive  characters  of  which  relate  especially 
to  rhythm,  namely,  (a)  shortened  inspiration  ;  (b)  pro- 
longed expiration  ;  and  (c)  interrupted  respiration. 

Adventitious  Respiratory  Sounds,  or  Rales. 

Adventitious  respiratory  sounds,  or,  adopting  the 
French  term,  rales,  are  distinguished  from  the  morbid 
signs  already  considered,  by  the  fact  that  they  have  no 
analogues  in  health  ;  in  other  words,  they  are  not  normal 
sounds  abnormally  modified,  but  wholly  new  sounds.  A 
convenient  classification  of  these  signs  is  based  on  the 
different  anatomical  situations  in  whicli  they  are  pro- 
duced. This  classification  is  as  follows  :  1st.  Laryngeal 
and  tracheal  rales ;  2d.  Bronchial  rales ;  3d.  Vesicular 
rales;  4th.  Cavernous  rales;  5th.  Pleural  raies;  and 
6th.  Indeterminate  rales.  Compared  with  each  other, 
as  regards  their  characters,  they  admit  of  being  divided 
into  dry  and  moist  rales,  the  latter  being  evidently  due 
to  the  presence  of  liquid. 

Laryngeal  and  Tracheal  Rales. — The  rales  produced 
within  the  larynx  and  trachea  may  be  either  moist  or 
dry.  The  moist  or  bubbling  sounds  are  produced  when 
mucus  or  other  liquid  accumulates  in  these  sections  of  the 
air-tubes.  This  occurs  frequently  in  the  moribund  state, 
and  the  sounds  are  then  known  as  the  '^  death  rattles.^' 
When  not  incident  to  this  state,  they  denote  either  insen- 
sibility to  the  presence  of  liquid,  as  in  coma,  or  inability 
to  effect  the  removal  of  the  liquid  by  acts  of  expectoration. 
The  sounds  are  heard  at  a  distance.  They  exemplify,  on 
a  large  scale,  moist  or  bubblingauscultatory  sounds  which 
are  produced  within  the  bronchial  tubes.  The  dry  rales 
j)roduced  within  the  larynx  or  trachea  are  caused  by 
spasm  of  the  glottis,  and  by  diminution  of  the  calibre, 


MOIST    BRONCUIAL    RALES.  107 

either  at  or  below  the  glottis,  from  oedema,  exudation, 
the  presence  of  a  foreign  body,  or  the  pressure  of  a 
tumor.  The  dry  sounds  are  distinguished  as  whistling, 
wheezing,  crowing,  whooping,  etc.  They  are  heard  at 
a  distance,  and  they  also  exemplify  auscultatory  sounds 
representing  analogous  conditions  in  the  bronchial  tubes. 
Characteristic  sounds  produced  at  the  glottis  by  spasm 
enter  into  the  diagnosis  of  certain  aifections,  namely, 
laryngismus  stridulus,  [)ertussis,  croup,  and  aneurism 
involving:  excitation  of  the  recurrent  larvno-eal  nerve. 
Other  sounds  are  due  to  paralysis  of  the  laryngeal 
muscles.  Again,  dry  sounds,  called  stridor,  produced 
by  stenosis  of  the  trachea  from  the  pressure  of  an  aneu- 
rismal  or  other  tumor,  cicatrization  of  ulcers,  and  morbid 
growths,  are  of  diagnostic  importance.  Although  audi- 
ble without  auscultation,  these  different  sounds,  with 
reference  to  the  precise  situation  at  which  they  are  pro- 
duced, may  sometimes  be  studied  with  advantage  by 
means  of  the  stethoscope. 

Moist  Bronchial  Rales. 

The  moist  bronchial  rales  are  bubbling  sounds  pro- 
duced in  diiferent  branches  of  the  bronchial  tree.  They 
are  sounds  of  which  the  "tracheal  rattles^'  are  an  ex- 
aggerated type.  They  may  be  imitated  by  blowing  into 
liquids  through  tubes  differing  in  size.  They  may  also 
be  produced  in  the  lungs  of  the  sheep  or  the  calf,  after 
removal  from  the  body,  by  injecting  into  the  bronchi 
glycerin  or  some  other  liquid,  and  imitating  the  respi- 
ratory acts  by  means  of  a  pair  of  bellows,  auscultation 
being  practiced  with  the  stethoscope  ap])lied  upon  the 
lung,  or  with  several  thicknesses  of  cloth  intervening. 
The  bubbles  seem  to  be  laro;e  or  small,  accordino;  to  the 


108  AUSCULTATION    IN    DISEASE. 

size  of  the  bronchial  tubes  in  which  they  are  produced. 
Apparent  differences  in  the  size  of  the  bubbles  are  dis- 
tinguished by  the  names  coarse  and  fine.  In  the  primary 
and  secondary  bronchial  branches  the  moist  sounds  are 
relatively  quite  coarse;  they  are  less  so  in  tubes  of  the 
third  or  fourth  dimensions;  in  smaller  tubes  they  be- 
come fine,  and  in  those  of  minute  size  they  become  ex- 
tremely fine.  Extremely  fine  bubbling  sounds  consti- 
tute what  is  known  as  the  subcrepitant  rale,  so  called 
because  it  approaches  in  character  to  the  crepitant  rale 
produced  within  the  air-vesicles  and  bronchioles.  We 
may  thus  judge  of  the  size  of  the  bronchial  tubes  in 
which  the  rales  are  produced  by  their  comparative 
coarseness  or  fineness.  Frequently,  however,  coarse  and 
fine  rales  are  intermingled,  and  generally  those  which 
are  either  coarse  or  fine  are  not  uniform,  but  appear  to 
be  of  unequal  size.  In  all  the  varieties  of  the  moist 
bronchial  rales,  tne  bubbling  character  of  the  sounds  is 
sufficient! V  distinctive  for  their  recognition.  The  differ- 
entiation  of  the  subcrepitant  from  the  crepitant  rale  alone 
involves  some  nice  points  of  distinction. 

Coarse  bubbling  rales  sometimes  occur  in  acute  bron- 
chitis affecting  the  larger  bro.ichial  tubes.  Their  occur- 
rence is  exceptional,  because,  in  general,  the  mucus 
within  the  tubes  does  not  accumulate  sulficiently  and  is 
too  consistent  for  the  production  of  bubbling  sounds. 
These  rales  occur  in  cases  in  which  the  mucus  is  un- 
usually thin  and  either  more  abundant  than  usual  or  an 
accumulation  takes  place  in  consequence  of  inability  to 
expectorate  freely.  These  conditions  are  wanting  in  the 
majority  of  the  cases  of  ordinary  acute  bronchitis.  A 
muco-purulent  liquid  in  cases  of  chronic  bronchitis  is 
better  suited  for  the  production  of  bubbling  sounds  than 


MOIST    BRONCHIAL    RALES.  109 

simple  mucus.  Moreover,  coarse  rales  are  heard  oftener 
in  children  than  in  adults,  because  the  former  do  not 
voluntarily  expectorate  as  freely  as  the  latter.  Serous 
transudation  (bronchorrhoea)  into  tubes  of  large  size  may 
give  rise  to  coarse  bubbling  rales,  and  also  the  presence 
of  blood  in  some  cases  of  profuse  haemorrhage.  In  bron- 
chitis and  bronchorrhoea  the  rales  are  heard  on  both 
sides  of  the  chest.  The  bubbling  rales,  whether  coarse 
or  fine,  are  heard  cither  with  the  act  of  inspiration  or  of 
exj)iration,  or  with  both  acts. 

Fine  bubbling  sounds  and  the  subcrepitant  rale  occur 
in  various  pathological  connections.  The  charac^ters  of 
the  subcrepitant  rale  are  to  be  borne  in  mind  with  refer- 
ence to  the  discrimination  from  the  crepitant.  The  most 
distinctive  character  is  the  moist  sound  or  bubbling; 
this  is  sufficiently  appreciable.  Other  characters  are, 
their  occurrence  frequently,  but  not  constantly,  in  expi- 
ration as  well  as  in  inspiration,  and  the  inequality  of  the 
fine  bubbling  sounds. 

The  subcrepitant  rale,  existing  over  the  chest  on  both 
sides,  is  diagnostic  of  bronchitis  affecting  the  smaller 
bronchial  tubes  (capillary  bronchitis),  when  taken  in 
connection  with  other  signs  and  the  symptoms.  The  rale 
exists  on  both  sides,  because  this,  as  well  as  bronchitis 
affecting  the  larger  tubes,  is  a  bilateral  affection.  The 
sign  is  of  great  j)ractical  value  in  the  diagnosis  of  that 
variety  of  bronchitis.  The  rale  also  occurs  on  both 
sides,  and  is  more  or  less  diffused  in  pulmonary  oedema. 
The  connection  with  the  latter  affection  is  shown  by  the 
associated  j)hysical  signs,  together  with  the  symptoms. 
In  so-called  capillary  bronchitis,  the  bubbling  is  due  to 
the  presence  of  thin  mucus,  and  in  pulmonary  oedema 

10 


110  AUSCULTATION    IN    DISEASE. 

to  serous  transudation  within  the  small  bronchial  rami- 
fications. 

Fine  bubbling  or  a  subcrepitant  rale  has  other  patho- 
logical connections,  as  follows: 

1.  It  occurs  in  lobar  pneumonia  during  the  stage  of 
resolution.  Here  it  is  due  to  the  presence  of  mucus  from 
a  bronchitis  limited  to  the  aifected  lobe  or  lobes,  and,  in 
a  measure,  to  liquefied  pneumonic  exudation.  It  is  con- 
sidered as  denoting  commencing  and  progressing  reso- 
lution in  pneumonia.  Sometimes  it  is  intermingled  with 
rales  which  are  more  or  less  coarse. 

2.  In  circum-cribed  pneumonia,  hsemorrhagic  infarc- 
tus,  and  pulmonary  apoplexy,  the  fine  or  subcrepitant 
rale,  often  associated  with  those  which  are  more  or  less 
coarse,  denotes  the  presence  of  mucus  or  of  blood  within 
the  bronchial  tubes.  The  rales  are  localized  in  space,  or 
in  spaces,  corresponding  to  the  situation  and  extent  of 
the  affection. 

3.  During  and  shortly  after  a  haemoptysis,  fine  rales 
limited  to  a  particular  situation  are  sometimes  heard, 
proceeding  from  blood  in  the  small  bronchial  tubes,  and 
indicating  the  situation  of  the  haemorrhage. 

4.  A  purulent  liquid  admits  of  bubbling  much  more 
readily  than  mucus ;  hence,  in  cases  of  chronic  bron- 
chitis with  an  expectoration  of  pus,  fine  and  coarse  bron- 
chial rales  are  more  frequent  tlian  in  acute  bronchitis. 
Pus,  also,  may  be  present  within  bronchial  tubes  of  small 
size,  not  as  a  product  of  bronchitis,  but  from  the  evacua- 
tion of  an  abscess  of  either  the  pulmonary  parenchyma, 
of  the  liver  or  some  other  adjacent  part,  and  from  per- 
foration of  lung  in  some  cases  of  empyema. 

5.  In  the  different  stages  of  phthisis,  moist  bronchial 
rales  are  usually  present.     The  liquid  in  the  tubes,  if  the 


MOIST    BRONCHIAL    RALES.  Ill 

disease  be  advanced,  is  derived,  in  part,  from  associated 
bronchitis,  and,  in  part,  from  liquefied  tuberculous  ex- 
udation. The  bubbling  sounds  may  be  more  or  less 
coarse  or  fine,  and  both  are  often  intermingled.  Early 
in  the  disease,  before  softening  of  the  exudation  has 
taken  place,  fine  bubbling,  or  the  subcrepitant  rale,  lim- 
ited to  the  summit  of  the  chest,  is  an  important  diagnostic 
sign.  It  belongs  among  the  accessory  physical  signs  on 
which  the  diagnosis  may  depend.  Here  the  liquid  is 
derived  from  a  coexisting  circumscribed  bronchitis. 

In  cases  of  fibroid  phthisis,  or  cirrhosis  of  lung,  moist 
rales,  coarse  and  fine,  are  generally  more  or  less  abun- 
dant and  diffused  over  the  whole,  or  the  greater  part,  of 
the  chest  on  the  affected  side. 

In  the  foregoing  account  of  the  moist  bronchial  rales, 
the  subcrepitant  rale  is  not  reckoned  as  a  sign  distinct 
from  fine  bubling  sounds.  Inasmuch  as  the  mechanism 
and  the  significance  are  the  same,  and  it  is  not  easy  to 
draw  a  line  of  demarcation  between  the  two,  the  distinc- 
tion is  unimportant.  It  is  sufficient  to  bear  in  mind  that 
very  fine  bubbling  sounds  are  called  subcrepitant,  be- 
cause they  are  somewhat  analogous  to  the  crepitant  rale, 
The  points  which  distinguish  the  latter  are,  however, 
w-ell-marked,  as  will  appear  when  the  characters  of  that 
sign  are  considered.  The  moist  rales  are  often  called 
mucous  rales.  This  name  is  obviously  inappropriate, 
since,  not  only  are  the  sounds  produced  by  other  liquids 
than  mucus,  but  other  liquids  are  best  suited  for  their 
production,  especially  in  the  large  and  medium-sized 
tubes.  The  several  varieties  of  the  moist  bronchial  rales 
may  be  produced  by  the  injection  of  a  liquid  in  varying 
quantity  into  the  bronchi  of  the  lungs  removed  from 


112  AUSCULTATION    IN    DISEASE. 

the  body  of  an  animal  of  sufficient  size,  e.  g.  of  the  sheep 
or  calf. 

The  moist  bronchial  rales,  whether  coarse  or  fine,  vary 
in  pitch  accordingly  as  the  lung  surrounding  the  tubes 
in  which  they  are  produced  is,  or  is  not,  solidified.  If 
the  lung  be  solidified,  the  pitch  is  high  ;  if  there  be  no 
solidification,  the  pitch  is  comparatively  low.  Tims,  the 
pitch  of  the  rales  is  high  in  the  second  stage  of  pneu- 
monia and  in  phthisis  with  considerable  solidification, 
whereas  the  pitch  is  low  in  bronchitis  and  pulmonary 
oedema.  If,  therefore,  the  respiratory  sound  be  sup- 
pressed, it  is  easy  to  determine  by  the  pitch  of  these 
rales  whether  the  lung  be  solidified  or  not,  and  to  judge 
measurably  of  the  degree  of  solidification.  Attention  to 
the  pitch  in  connection  with  these  rales  is  sometimes  of 
value  in  diagnosis. 

Dry  Bronchial  Rales. 

All  adventitious  sounds  which  are  not  moist,  produced 
within  the  air-tubes  below  the  trachea,  are  embraced 
under  the  name  dry  bronchial  rales.  The  sounds  are 
many  and  varied  in  character.  They  are  often  musi- 
cal notes.  Frequently  they  are  suggestive  of  certain 
familiar  sounds,  such  as  the  chirping  of  birds,  the  cry 
of  a  young  animal,  snoring  in  sleep,  cooing  of  pigeons, 
humming  of  the  mosquito,  the  note  of  the  violoncello, 
etc.,  etc.  They  are  often  heard  at  a  distance,  and 
characterized  as  wheezing  sounds.  An  interrupted  or 
clicking  sound  is  not  uncommon.  All  these  varieties 
are  practically  unimportant,  and  it  would  be  a  needless 
refinement  to  consider  particular  varieties  as  distinct 
signs.  The  only  distinction  which  it  is  desirable  to 
make  is  into  the  sibilant  and  sonorous  rales.     This  dis- 


DRY    BRONCHIAL    RALES.  113 

tinction  is  based  on  difference  in  pitch  ;  sibilant  rales 
are  hi^^h,  and  sonorous  rales  are  low  in  pitch.  As  a 
rule,  the  sibilant  rales  are  produced  in  the  small  and  the 
sonorous  rales  in  the  larger  sized  bronchial  tubes.  The 
sounds  may  accompany  either  inspiration  or  expiration, 
or  both.  The  sibilant  and  sonorous  rales  are  often  in- 
termingled. There  may  be  sibilant  rales  with  inspira- 
tion, and  sonorous  rales  with  expiration,  within  the 
same  situation.  Moreover,  these  rales  are  found  often 
to  vary  from  minute  to  minute,  being  at  one  instant  sibi- 
lant and  at  another  sonorous.  Students  are  liable  to 
confound  sonorous  rales  with  bronchial  breathing  and 
sometimes  friction- sounds. 

The  ])hysical  condition  represented  by  the  dry  rales  is 
diminished  calibre  of  the  air-tubes  at  certain  points, 
and  especially  in  consequence  of  spasm  of  the  bronchial 
muscular  fibres.  The  latter  constitutes  the  essential 
pathological  condition  in  a  paroxysm  of  asthma;  and  in 
this  affection  the  dry  rales  are  always  marked.  Their 
diagnostic  importance  relates  chiefly  to  asthma.  Both 
sibilant  and  sonorous  rales  are  present  and  diff'used  over 
the  entire  chest.  Wheezing  sounds  with  expiration  are 
heard  by  the  patient,  and  by  others  at  a  distance.  A 
single  paroxysm  of  asthma  affords  an  opportunity  for  the 
student  to  observe  all  the  varieties  and  fluctuations  of 
these  rales.  Taken  in  connection  with  other  signs  and 
the  symptoms,  the  rales  are  pathognomonic  of  asthma. 

More  or  less  spasm  of  the  bronchial  muscular  fibres 
occurs  in  certain  cases  of  bronchitis,  without  being  suffi- 
ciently great  and  extensive  to  give  rise  to  a  paroxysm 
of  asthma,  or  even  any  embarrassment  of  respiration. 
Under  these  circumstances  the  rales  are  less  marked 
and  diffused.     An  asthmatic  element   may  be  said  to 


114  AUSCULTATION    IN    DISEASE. 

enter,  more  or  less,  into  these  cases.  Narrowing  of 
bronchial  tubes  by  tenacious  mucus  which  gives  rise  to 
no  bubbling  sounds,  and,  perhaps  unequal  swelling  of 
the  mucous  membrane,  may  also  occasion  sibilant  and 
sonorous  rales. 

Dry  rales  at  the  summit  of  the  chest  are  not  infrequent 
in  cases  of  phtiiisis,  due  to  spasm,  the  presence  of  mucus, 
or  to  swelling  of  the  mucous  membrane.  They  are  some- 
times quite  annoying  to  phthisical  patients. 

Clicking  sounds  are  suggestive  of  the  sudden  separa- 
tion of  tenacious  mucus  from  the  walls  of  the  bronchial 
tubes.  These  are  sufficiently  common  in  bronchitis  and 
in  phthisis. 

Vesicular  or  Crepitant  Rale. 

This  is  the  only  vesicular  rale.  It  is  usually  con- 
sidered to  be  produced  within  the  air-vesicles,  but  prob- 
ably, the  terminal  bronchial  tubes  or  bronchioles  par- 
ticipate in  its  production. 

It  is  to  be  distinguished  from  very  fine  bubbling  sounds, 
or  the  subcrepitant  rale.  The  points  of  distinction  are 
as  follows  :  The  sounds  are  not  moist  but  dry  ;  they  are 
crackling,  not  bubbling  in  character.  They  may  be  de- 
fined to  be  very  fine,  dry,  crackling  sounds.  This  point 
of  difference  is  very  distinctive.  There  are,  however, 
other  differential  points.  The  crackling  sounds  are  equal, 
whereas,  fine  bubbling  sounds  are  unequal,  that  is,  they 
give  the  impression  of  bubbles  of  unequal  size.  The 
crepitating  sounds  are  heard  at  the  end  of  the  inspira- 
tory act,  and  especially  at  the  end  of  a  forced  inspira- 
tion, the  subcrepitant  rale,  on  the  other  hand,  being  heard 
often  with  or  near  the  beginning  of  inspiration,  and,  per- 
haps, ceasing  before  the  end  of  the  inspiratory  act.  An- 
other distinctive  feature  is  the  abrupt  development  of 


VESICULAR    OR    CREPITANT    RALE.  115 

tlie  crepitant  rale;  there  Is  a  shower  of  crackles,  as  it 
were,  at  the  end  of  a  forced  inspiration.  Finally,  the 
rale  is  never  heard  in  expiration.  The  apparent  excep- 
tions to  this  statement  are  instances  in  which  the  crepi- 
tant and  the  subcrepitant  rale  are  associated.  This  is 
not  very  infrequent,  and,  with  a  practical  knowledge  of 
the  characters  of  each,  it  is  by  no  means  difficult  to  ap- 
preciate the  combination  of  the  two  signs.  In  fact,  the 
combination  affords  an  excellent  opportunity  to  illustrate 
the  distinctive  characters  of  each  ;  the  fine  bubbling  at 
or  near  the  beginning  of  inspiration,  followed  by  the  fine 
crackling  at  the  end  of  this  act,  and  the  former  perhaps 
reproduced  in  the  act  of  expiration. 

There  are  various  modes  in  which  the  crepitant  rale 
may  be  irnitated;  for  examples,  rubbing  together  a  lock 
of  hair  near  the  ear,  throwing  fine  salt  upon  live  coals 
or  into  a  heated  vessel,  igniting  a  train  of  gunpowder, 
and  alternately  pressing  and  separating  the  thumb  and 
finger  moistened  with  a  solution  of  gum  arable  and  held 
near  the  ear.  A  perfect  representation  is  afforded  by 
squeezing  a  piece  of  an  artificial  preparation  known  as 
the  india-rubber  sponge,  and  observing  the  sound  pro- 
duced by  the  separation  of  the  walls  of  the  interstices 
when  the  piece  expands  from  its  elasticity.  This  pre})a- 
ration  exemplifies  the  true  mechanism  of  the  sign  as 
described,  first,  by  the  late  Dr.  Carr,  of  Canandaigna, 
N.  Y.,  in  an  article  published  in  the  American  Journal 
of  31edical  Sciences,  in  October,  1842.^  Expansion  of 
the  lungs  of  the  sheep  or  calf,  after  removal  from  the 
body,  the  stethoscope  being  applied  to  the  lung-surface, 
gives,  in  certain  situations,  a  well-marked  crepitant  rale. 

"•  Vide  article  by  the  author  in  the  New  York  Monthly  Med. 
Journ.  for  Feb.,  1869. 


116  AUSCULTATION    IN    DISEASE. 

The  crepitant  rale  is  the  diagnostic  sign  of  pneumonia. 
It  very  rarely  occurs  in  any  other  })athological  connec- 
tion. Of  all  respiratory  signs,  this  is  most  entitled  to 
be  called  pathognomonic.  It  belongs  especially  to  the 
first  stage  of  acute  pneumonia.  It  is  not  invariably 
present,  but  it  occurs  in  the  majority  of  cases  of  acute 
pneumonia.  In  the  second  stage,  or  tiie  stage  of  solidifi- 
cation, the  rale  generally  disappears.  It  not  infrequently 
is  rej)roduced  in  the  stage  of  resolution,  and  it  is  then 
called  the  returning  crepitant  rale.  In  the  latter  stage 
it  is  often  found  in  combination  with  the  subcrepitant 
rale.  The  practical  value  of  this  sign  relates  chiefly  to 
the  diagnosis  of  pneumonia. 

It  is  stated  that  the  crepitant  rale  is  sometimes  found 
in  cases  of  pulmonary  oedema,  and  during  or  directly 
after  an  attack  of  haemoptysis.  If  it  ever  occur  in  these 
cases,  the  instances  must  be  extremely  rare.  The  state- 
ment is  perhaps  based  on  the  occurrence  of  the  subcrepi- 
tant, this  being  confounded  with  the  crepitant  rale.  It 
occurs  transiently  under  the  following  circumstances:  A 
patient  wlio  has  been  confined  for  some  time  in  bed, 
lying  on  the  back,  and  much  enfeebled  with  any  disease, 
if  suddenly  raised  to  a  sitting  posture  and  auscultated,  a 
crepitant  rale  is  often  found  on  the  posterior  aspect  of 
the  chest  at  the  end  of  a  forced  inspiration.  The  rale 
disappears  after  a  few  forced  inspirations.  It  is  heard, 
not  on  one  side  only,  but  on  l)oth  sides.  The  explana- 
tion is,  that  during  the  recumbent  posture  continued  for 
some  time,  and  the  patient  breathing  feebly,  enough  of 
the  air-vesicles  and  bronchioles  become  agglutinated  by 
means  of  a  little  sticky  transudation  to  give  rise  to 
crackling  sounds  in  a  few  forced  inspirations.    It  may  be 


CAVERNOUS    OR    GURGLING    RALE.  117 

of  use  to  mention  that  if  the  stethoscope  be  applied  to 
the  anterior  surface  of  a  cliest  much  covered  with  hair, 
the  movements  of  the  pectoral  extremity  of  the  instru- 
ment in  the  act  of  inspiration  may  produce  a  sound  iden- 
tical with  the  crepitant  rale. 

A  crepitant  rale  at  the  summit  of  the  chest,  within  a 
circumscribed  space,  is  one  of  the  accessory  signs  of 
phtliisis.  It  denotes  a  circumscribed  pneumonia  which 
clinical  experience  shows  to  be  generally  secondary  to 
phthisis;  hence  the  diagnosti(3  significance  of  the  sign. 

Cavernous  or  Gurg^ling  Rale. 

A  pulmonary  cavity  of  considerable  size,  containing  a 
certain  quantity  of  liquid,  and  communicating  freely  with 
bronchial  tubes,  furnishes  a  rale  which  is  characteristic. 
The  character  of  the  sound  is  expressed  as  fully  as 
possible  by  the  term  gurgling.  The  sound  is  produced 
by  large  bubbling  and  the  agitation  of  the  liquid  within 
the  cavity.  It  may  be  compared  to  the  sound  produced 
by  the  boiling  of  a  liquid  in  a  flask  or  large  test-tube. 
The  sound  is  sometimes  high  pitched  and  amphoric,  but 
generally  it  is  low  in  pitch.  It  is  heard  with  more  or 
less  intensity  within  a  circumscribed  space  almost  in- 
variably at  or  near  the  summit  of  the  chest;  but,  if 
intense,  the  sound  is  diffused,  and  it  may  be  sometimes 
heard  at  a  distance.  Its  diagnostic  importance  relates 
to  the  advanced  stage  of  phthisis.  The  rale  is  heard 
chiefly  or  exclusively  in  the  act  of  inspiration.  It  may 
be  produced  by  the  act  of  coughing  sometimes  with 
greater  intensity  than  by  respiration. 


118  AUSCULTATION    IN    DISEASE. 

Pleural  Rales — Friction-Sounds — Metallic  Tinkling — 

Splashing. 

The  signs  embraced  under  the  name  pleural  rales  are, 
1st.  Sounds  produced  by  the  rubbing  together  of  the 
pleural  surfaces,  and  hence  called  friction-sounds ;  2d. 
Metallic  tinkling;  and  3d.  Splashing  or  succussion 
sounds. 

Friction- Sounds. — Movements  of  the  pleural  surfaces 
upon  each  other  take  place  in  inspiration  and  expiration; 
but  in  health  these  movements  occasion  no  sound. 
Sounds  are  produced  when  the  surfaces  are  covered  with 
a  recent  fibrinous  exudation  which  prevents  the  normal 
continuous,  unobstructed  movements,  and  when  the  sur- 
faces are  roughened  with  dense  lymph  or  other  morbid 
products.  The  sounds  are  generally  interrupted,  that 
is,  two,  three,  or  more  sounds  occur  during  the  act  of 
inspiration  or  expiration,  or  during  both  acts.  The 
intensity  of  the  sounds  varies  much  in  different  cases. 
A  slight  grazing  sound  only  may  be  heard,  or,  on  the 
other  hand,  the  sounds  may  be  so  loud  as  to  be  heard  by 
the  patient  and  by  others  at  a  distance.  The  character 
of  the  sounds  is  variable.  The  slight  rubbing  or  grazing 
character  may  be  imitated  by  placing  over  the  ear  the 
palmar  surface  of  one  hand,  and  moving  over  its  dorsal 
surface  slowly  the  pulpy  portion  of  a  finger  of  the  other 
hand.  In  some  instances,  however,  the  rough  character 
of  the  sounds  is  expressed  by  such  terms  as  rasping, 
grating,  and  creaking.  In  these  instances  the  sounds 
denote  density  of  the  morbid  product  which  roughens  the 
pleural  surfaces.  In  connection  with  very  rough  sounds, 
vibration  of  the  walls  of  the  chest,  or  fremitus,  is  some- 
times perceived  by  palpation. 

Aside  from  the  character  of  the  sounds  as  just  stated, 


FRICTION-SOUNDS.  119 

they  are  distinguished  by  their  apparent  nearness  to  the 
car;  they  seem  sometimes  to  be  produced  upon  the  sur- 
face of  tlie  chest.  They  are  sometimes  intensified  by 
firm  pressure  of  the  stethoscope  upon  the  chest.  After 
a  little  practical  knowledge  of  these  sounds  they  can 
hardly  be  confounded  with  any  other  rales. 

Pleuritic  friction-sounds  generally  denote  pleurisy. 
In  cases  of  pleurisy  with  effusion,  slight  rubbing  or 
grazing  is  sometimes  heard  before  much  liquid  accumu- 
lates within  the  pleuritic  cavity.  The  physical  condi- 
tions, however,  after  the  effusion  has  been  removed,  are 
much  morefavorable  for  the  production  of  friction-sounds, 
and  they  are  often  now  rough  in  character.  They  may 
be  transient,  or  they  may  continue  for  a  considerable 
period,  their  duration  depending  on  the  arrest  of  the 
movements  of  the  pleural  surfaces  by  means  of  either 
agglutination  with  lymph,  or  adhesion  from  the  growth 
of  areolar  tissue. 

Pleuritic  friction-sounds  occur  not  infrequently  in 
cases  of  pneumonia,  denoting,  in  this  connection,  coex- 
isting pleurisy. 

Slight  rubbing  or  grazing  at  the  summit  of  the  chest 
is  one  of  the  accessory  signs  of  phthisis.  It  denotes  a 
circumscribed,  dry  j)leurisy,  which,  as  clinical  experience 
show^s,  is  generally  secondary  to  phthisis,  and  hence  the 
diao-nostic  sio;nificance  of  the  siirn. 

In  the  foregoing  instances  in  which  friction-sounds 
are  stated  to  occur,  their  significance  relates  to  pleurisy. 
In  some  rare  instances  the  sounds  are  produced  by 
miliary  tubercles  or  carcinomatous  nodules  projecting 
beyond  the  plane  of  the  visceral  pleural  surface,  without 
pleuritic  inflammation. 


120  AUSCULTATION    IN    DISEASE. 

Metallic  TinhUng. — This  is  a  vocal  as,  well  as  a  re- 
spiratory sign.  It  is  also  produced  by  acts  of  coughing, 
and  sometimes  by  the  act  of  deglutition.  The  name  ex- 
presses the  distinctive  character  of  the  sign.  It  consists 
in  a  series  of  tinkling  sounds  of  a  high-f)itched,  silvery, 
or  metallic  tone.  The  number  of  sounds  varies  from  a 
single  sound,  to  two,  three,  or  more  sounds,  during  an 
act  of  either  iufspiration  or  expiration.  Tins  sign  may 
be  imitated  in  various  way<«,  by  means  of  an  india-rubber 
bag  of  considerable  size.  Forcing  a  liquid  into  the  bag 
with  Davidson's  Syringe,  tapping  the  bag  with  the  finger, 
or  shaking  it,  will  produce  tinkling  sounds.  The  best 
mode  of  artificial  representation  of  the  sign  is  to  connect 
the  bag  with  a  flexible  tube,  the  latter  containing  a  few 
drops  of  liquid,  and  blowing  into  the  tube  so  as  to  pro- 
duce bubbles  at  the  communication  of  the  tube  with  the 
bag.  In  this  latter  experin)ent  it  is  not  necessary  that 
the  bag  contain  any  liquid.  It  occurs  irregularly,  that 
is,  it  is  not  ])resent  in  every  act  of  breathing,  but  is  heard 
at  variable  intervals.  It  may  sometimes  be  produced  by 
forced,  when  it  is  not  heard  iu  tranquil,  breathing.  It 
can  only  be  confounded  with  tinkling  sounds  sometimes 
produced  within  the  stomach.  The  latter,  however,  are 
easily  discriminated  by  their  situation,  and  the  absence 
of  associated  signs  denoting  the  affections  of  the  chest  in 
which  the  sign  occurs. 

Metallic  tinkling  is  the  sign  of  pneumothorax  with 
perforation  of  lung.  In  the  great  majority  of  the  cases 
in  which  it  is  found,  it  is  diagnostic  of  this  aifection.  It 
is,  however,  always  associated  with  other  physical  signs 
corroborative  of  the  diagnosis. 

It  is  a  rare  sign,  in  cases  of  phthisis,  of  a  large  pulmo- 
nary cavity,  the  conditions  for  its  production  being  analo- 


INDETERMINATE    RALES.  121 

gous  to  those  in  pneiimo-hydrothorax,  namely,  a  space  of 
considerable  size  containing  air,  the  space  communicating 
with  bronchial  tubes. 

Splashing,  or  Succussion  Sounds. — This  sign  is  pro- 
duced by  succussion,  which  is  reckoned  as  one  of  the 
different  modes  of  j)hysical  exploration.  Sounds  thus 
produced  are  not  infrequently  heard  at  some  distance; 
generally,  however,  succussion  is  practiced  while  the  ear 
is  a})plied  to  the  chest,  so  that  properly  enough  the  sign 
may  be  embraced  among  the  auscultatory  signs,  although 
not  produced  by  respiration. 

Splashfng  is  pathognomonic  of  either  pnenrao-liydro- 
thorax  or  pueumo-pyothorax.  It  is  especially  valuable  as 
a  sign  of  these  affections  because  it  is  almost  invariably 
available.  The  instances  are  extremely  few  in  which  the 
sign  is  wanting  when  air  and  liquid  are  contained  in  the 
pleural  cavity.  It  is  obtained  by  jerking  the  body  of  the 
patient  with  a  quick,  somewhat  forcible  movement,  the 
ear  being  very  near  to,  or  in  contact  with,  the  chest. 

The  sound  is  like  that  produced  when  a  bottle  par- 
tially filled  with  liquid  is  shaken.  The  sound  is  often 
high-pitched  and  amphoric  in  quality.  The  only  liability 
to  error  is  in  confounding  with  this  sign,  splashing  pro- 
duced within  the  stomach.  Attention  to  other  signs  will 
always  protect  against  this  error. 

Indeterminate  Bales. — Under  this  head  may  be  em- 
braced some  sounds  sufficiently  recognizable,  but  inde- 
terminate as  regards  the  rationale  of  their  production 
and  the  physical  conditions  which  they  represent.  They 
may  be  designated  crumplingand  crackling  sounds.  The 
former  are  probably  due  to  pleuritic  rubbing,  and  the 
latter  to  the  separation  of  some  slightly  adherent  air- 
vesicles  or  bronchioles.     Their  diagnostic  value  relates 


122  AUSCULTATION    IN    DISEASE. 

only  to  the  early  stage  of  phthisis.  In  conjunction  with 
other  signs,  any  indeterminate  rale,  if  limited  to  the 
summit  of  the  chest,  and  especially  to  one  side,  has  some 
weight  in  the  diagnosis.  Crumpling  and  crackling  sounds, 
however,  are  not  uncommon  in  healthy  persons  at  the 
end  of  forced  inspiration.  The  fact  of  their  presence  at 
both  summits,  and  the  absence  of  other  morbid  signs,  are 
the  grounds  for  not  considering  them  as  evidence  of  dis- 
ease. They  are  found  in  health  especially  if  the  binau- 
ral stethoscope  be  employed.  Their  diagnostic  signifi- 
cance, thus,  depends  on  limitation  to  the  summit  of  the 
chest  on  one  side,  and  association  with  other  signs  point- 
ing to  incipient  phthisis. 

The  Vocal  Signs  of  Disease. 

The  vocal  signs  of  disease,  with  the  exception  of 
metallic  tinkling,  which  is  a  vocal  as  well  as  respiratory 
sign,  may  all  be  considered  as  abnormal  modifications  of 
the  normal  vocal  resonance  and  of  the  normal  bronchial 
whisper.  The  student  must,  therefore,  be  familiar  with 
the  distinctive  characters  of  these  two  normal  signs  before 
he  is  prepared  to  enter  upon  the  study  of  the  abnormal 
modifications  {vide  pages  77  and  82).  He  must  bear  in 
mind  the  facts  which  have  been  presented  in  relation  to 
the  normal  vocal  fremitus  {vide  page  77).  The  rules 
given  for  auscultation  of  the  voice  are  also  to  be  observed 
{vide  page  7G).  Embracing  the  abnormal  modifications 
of  the  loud  voice,  the  whisper  and  fremitus,  the  following 
are  the  signs  to  be  considered:  Bronchophony;  Whis- 
pering Bronchophony ;  ^Kgophony  ;  Increased  Vocal 
Resonance;  Increased  Bronchial  Whisper;  Cavernous 
Whisper;  Pectoriloquy;  Amphoric  Voice  or  Echo; 
Diminished  and   Suppressed  Vocal  Resonance;  Dimin- 


BRONCHOPHONY,  123 

ished   and    Suppressed  Vocal   Fremitus,  and  Metallic 

Tinkling. 

Bronchophony. 

Bronchophony  has  the  same  import  as  bronchial  or 
tubular  respiration.  Like  the  latter  sign,  it  represents 
complete  or  considerable  solidification  of  lung.  Gene- 
rally the  two  signs  are  associated,  but  either  may  be 
present  without  the  other. 

The  characters  which  are  distinctive  of  bronchophony, 
as  compared  with  the  normal  vocal  resonance,  are  these: 
The  vocal  sound  seems  concentrated,  in  most  cases  near 
the  ear,  and  the  pitch  is  more  or  less  raised.  These 
characters  are  in  contrast  with  the  diffusion,  distance, 
and  lownessof  pitch  of  the  normal  vocal  resonance.  The 
intensity  of  the  sound  is  variable;  it  may  be  greater  or 
less  than  the  intensity  of  the  normal  resonance.  A  con- 
centrated, high-pitched  sound,  however  feeble,  is  not  less 
a  sign  of  complete  or  considerable  solidification  of  lung, 
that  is,  it  is  not  less  bronchophony,  than  when  the  sound 
is  intense. 

Vocal  fremitus  is  always  to  be  discriminated  from 
vocal  resonance.  The  fremitus  associated  with  broncho- 
phony may,  or  may  not,  be  greater  than  the  fremitus  of 
health.  Not  infrequently  the  fremitus  is  less  than  in 
health. 

It  is  to  be  borne  in  mind  that  in  some  healthy  persons 
bronchophony  exists  at  the  summit  of  the  chest,  espe- 
cially on  the  right  side,  over  the  primary  bronchus. 
Existing  alone  in  this  situation,  it  may  not  be  abnormal. 

Representing  complete  or  considerable  solidification 
of  lung,  this  sign  occurs  in  the  different  affections  in 
which  bronchial  or  tubular  respiration  has  been  seen  to 
occur  [vide  page  9fS),  namely,  lobar  pneumonia,  phthisis, 


124  AUSCULTATION    IN    DISEASE. 

chronic  or  fibroid  pneumonia,  condensation  of  lung  from 
either  pleuritic  eifusion,  the  accumulation  of  air  in  the 
pleural  cavity  or  the  pressure  of  a  tumor,  collapse  of 
pulmonary  lobules,  coagulation  of  blood  within  the  air- 
vesicles,  and  carcinoma  of  lung. 

For  the  production  of  bronchophony,  a  less  degree  of 
solidification  is  requisite  than  for  the  production  of  bron- 
chial or  tubular  respiration.  Hence,  bronchophony  may 
be  associated  with  a  broncho- vesicular,  as  well  as  with  a 
purely  bronchial  respiration.  This  is  illustrated  in  the 
resolving  stage  of  pneumonia.  When  resolution  has  pro- 
gressed sufficiently  for  the  bronchial  to  give  place  to  the 
broncho- vesicular  respiration,  well-marked  bronchophony 
is  often  found  to  continue,  ceasing  at  a  later  period  in 
the  resolving  stage. 

The  apparent  nearness  to  the  ear  of  the  vocal  sound 
in  bronchophony  is  wanting  if  a  certain  quantity  of  liquid 
intervene  between  the  solidified  lung  and  the  w^alls  of 
the  chest  at  the  situation  auscultated.  The  voice  under 
these  conditions  seems  to  be  more  or  less  distant.  This 
difference  is  readily  appreciated,  ^¥ith  this  apparent 
distance  of  the  bronchophonic  voice,  in  some  instances  is 
associated  the  modification  which  is  characteristic  of 
another  sign,  namely,  legophony. 

Whispering  Bronchophony. 

The  characters  of  this  sign  correspond  to  those  of  the 
expiratory  sound  in  the  bronchial  or  tubular  respiration 
{vide  page  93).  The  sound  is  more  or  less  intensified, 
high  in  pitch  and  tubular  in  quality.  If  the  patient 
pronounce  numerals  in  a  forced  whisper,  the  characters 
are  generally  more  marked  than  in  the  expiratory  sound 
in  forced  breathing.    The  significance  of  this  sign  is  the 


^GOPHONY.  125 

same  as  that  of  the  bronchial  or  tubular  respiration,  and 
of  bronchophony  with  the  loud  voice. 

JEgophony. 

This  sign  is  a  modification  of  bronchophony.  As 
regards  concentration  and  pitch,  it  has  the  characters  of 
bronchophony,  the  distinctive  features  being  apparent 
distance  from  the  ear,  and  tremulousness  or  a  bleating 
tone.  From  the  latter  the  name  is  derived,  the  term 
signifying  the  cry  of  the  goat.  The  characters  which 
distinguish  the  sign  from  bronchophony  are  readily 
enough  appreciated,  and  it  represents  a  physical  con- 
dition added  to  solidification  of  lung.  This  physical 
condition  is  the  presence  of  liquid  effusion.  The  sign  is 
rarely  present  in  cases  of  large  effusion.  It  occurs 
usually  when  the  chest  is  about  half  filled  with  liquid, 
and  the  lung  at  the  level  of  the  liquid  is  sufficiently  con- 
densed to  give  rise  to  bronchophony.  This  condition, 
under  these  circumstances,  involves  agglutination  of  lung 
above  the  portion  condensed  by  pressure.  The  sign  also 
sometimes  occurs  in  cases  of  pleuro-pneumonia,  the 
solidification  in  these  cases  being  due  to  pneumonic 
exudation.  As  a  sign  of  liquid  eifusion  it  possesses 
diagnostic  value,  although,  owing  to  the  fact  that  the 
existence  of  eifusion  is  easily  determined  by  other  signs, 
it  may  be  said  to  be  superfluous.  When  the  person 
examined  speaks  with  the  teeth  approximated,  broncho- 
phony has  somewhat  of  the  character  of  liegophony. 

Increased  Vocal  Resonance  and  Fremitus. 

The  distinctive  character  of  this  sign  is  an  increase  of 
the  intensity  of  the  resonance  without  notable  change  in 
other   respects.     The    resonance    may  be  more  or  less 

11 


126  AUSCULTATION    IN    DISEASE. 

intensified,  but  it  is  distant,  diffused,  and  comparatively 
low  in  pitch  ;  in  other  words,  the  characters  of  broncho- 
phony are  wanting.  The  differential  points  between 
bronchophony  and  increased  resonance  should  be  clearly 
apprehended,  bearing  in  mind  that  the  intensity  of  the 
sound  in  bronchophony  may,  or  may  not,  be  greater  than 
the  normal  resonance. 

Increased  vocal  resonance  occurs  when  the  lung  is 
solidified,  the  solidification  not  sufficient  in  degree  to 
produce  bronchophony.  Lung  slightly  or  moderately 
solidified  gives  rise  to  an  increase  of  intensity  ;  if  the 
solidification  become  considerable  or  complete,  broncho- 
phony takes  the  place  of  the  simple  increase  of  intensity. 
Thus,  at  an  early  period  in  pneumonia,  increased  vocal 
resonance  precedes  bronchophony  ;  and  in  the  stage  of 
resolution  the  reverse  of  this  takes  place,  namely,  in- 
creased vocal  resonance  follows  bronchophony,  the  lat- 
ter ceasing  when  resolution  has  progressed  to  a  certain 
extent. 

Contrary  to  what  would  perhaps  be  anticipated  in  the 
instances  just  cited,  the  intensity  of  the  sound  when 
bronchophony  is  present  may  be  not  only  not  increased, 
but  diminished  below  that  of  health  ;  that  is,  in  the  first 
stage  of  pneumonia  the  increased  intensity  may  cease 
when  bronchophony  occurs,  and  return  when  broncho- 
phony disappears. 

Increase  of  the  vocal  resonance  occure  in  connection 
with  pulmonary  cavities.  Over  a  cavity  of  considerable 
size  situated  near  the  superficies  of  the  lung,  the  vocal 
resonance  is  sometimes  extremely  intense  without  any 
bronchophonic  characters.  The  latter,  if  present,  denote 
considerable  solidification  either  around  the  cavity,  or 
between  it  and  the  walls  of  the  chest.     From  the  pres- 


INCREASED  VOCAL   RESONANCE   AND  FREMITUS.  127 

ence  or  tlie  absence  of  bronchoi)lionic  characters  with 
greatly  increased  intensity  of  resonance,  the  auscultator 
can  judge  whether  the  cavity  be,  or  be  not,  in  proximity 
to  considerable  solidification  of  Itmg. 

Irrespective  of  the  cavernous  stage  of  phthisis,  the 
sign  is  of  diagnostic  importance  in  the  different  affections 
which  involve  moderate  or  slight  solidification  of  lung, 
namely,  pneumonia  early  in  the  disease  and  in  the  stage 
of  resolution,  phthisis,  over  the  compressed  lung  in  pleu- 
risy with  moderate  effusion,  collapse  of  pulmonary  lob- 
ules, hsemorrhagic  infarctus,  and  carcinoma  of  lung.  Into 
the  diagnosis  of  all  these  affections,  both  bronchophony 
and  increased  vocal  resonance  enter;  the  former  when 
solidification  is  considerable  or  complete,  and  the  latter 
when  it  is  slight  or  moderate.  IncreavSed  vocal  resonance 
is  especially  valuable  in  the  diagnosis  of  early  or  incipi- 
ent phthisis.  An  abnormal  resonance,  however  slight,  at 
the  summit  of  the  chest  on  one  side,  is  an  important  sign 
in  that  affection.  In  determining  an  abnormal  resonance 
on  the  right  side,  either  at  the  summit  or  elsewhere,  al- 
lowance must  always  be  made  for  the  normally  greater 
resonance  on  this  side. 

Increased  vocal  resonance  has  the  same  import  as 
broncho- vesicular  respiration.  These  two  signs,  how- 
ever, are  not  always  in  the  same  proportion  ;  that  is,  the 
characters  of  the  latter  maybe  marked  out  of  proportion 
to  the  amount  of  the  increase  of  the  vocal  resonance,  and 
vice  versa. 

Increased  vocal  fremitus  generally  accompanies  in- 
creased vocal  resonance,  and  it  denotes  solidification  of 
lung.  Fremitus,  however,  and  resonance  are  not  always 
in  equal  proportion,  that  is,  either  may  be  increased 
more  than  the  other.     An  increased  fremitus  is  some- 


128  AUSCULTATION    IN    DISEASE. 

times  of  value  in  the  diagnosis  of  phthisis.  The  greater 
fremitus  on  the  right  side  of  the  chest  is  always  to  be 
borne  in  mind,  and  due  allowance  is  to  be  made  for  this 
disparity  in  determining  that  the  fremitus  is  increased. 

Increased  Bronchial  Whisper. 

The  significance  of  this  sign  is  the  same  as  that  of 
increased  vocal  resonance  and  the  broncho-vesicular 
respiration;  it  represents  the  same  physical  condition  as 
the  two  latter  signs,  namely,  solidification  of  lung, 
greater  or  less,  but  below  the  degree  requisite  to  give 
rise  to  bronchophony  and  bronchial  respiration.  Its 
diagnostic  application  is,  therefore,  involved  in  the  same 
pulmonary  affections. 

The  characters  of  the  sign  are  those  which  belong  to 
the  expiratory  sound  in  the  broncho-vesicular  respira- 
tion. They  consist,  therefore,  of  increase  of  intensity, 
a  quality  more  or  less  tubular,  and  the  pitch  raised, 
these  modifications  of  the  normal  expiratory  sound 
varying  in  degree  between  the  slightest  appreciable 
morbid  change  and  a  close  approximation  to  the  bron- 
chophonic  whisper.  The  modifications  in  degree  cor- 
respond to  the  degree  of  solidification.  To  appreciate 
the  characters  of  this  sign,  it  must  be  studied  in  com- 
parison with  those  of  the  normal  bronchial  whisper  in 
different  portions  of  the  chest.  The  most  important 
of  the  diagnostic  applications  of  the  sign  is  in  cases  of 
phthisis  in  its  early  stage.  In  this  application,  the 
points  of  normal  disparity  between  the  two  sides  of  the 
chest  at  the  summit  are  to  be  borne  in  mind,  and  due 
allowance  made  for  them  {vide  page  83). 

A  greater  intensity  of  the  bronchial  whisper  at  the 
right  than  at  the  left  summit  is  not  evidence  of  disease; 


PECTORILOQUY.  129 

but  greater  intensity  at  the  left  summit  is  always  abnor- 
mal. As  a  rule,  the  |)it('h  of  the  normal  bronchial  whisper 
at  the  left,  is  higher  than  that  at  the  right,  summit;  if, 
therefore,  with  a  greater  intensity  of  the  whisper  at  the 
right  summit,  it  be  a  matter  of  doubt  whether  it  denote 
disease  or  not,  when  the  pitch  is  higher  at  this  summit, 
it  is  to  be  considered  as  morbid. 

Cavenioiis  Whisper. — The  characters  distinctive  of 
the  cavernous  whisper  are  those  of  the  expiratory  sound 
in  the  cavernous  respiration,  namely,  lowness  of  pitch, 
and  the  quality  blowing,  that  is,  non-tubular.  The  in- 
tensity of  the  sound  is  variable.  It  is  limited  to  a  cir- 
cumscribed space  corresponding  to  the  situation  and  size 
of  the  cavity.  Not  infrequently  the  characters  of  the 
sign  are  brought  into  contrast  with  those  of  whispering 
bronchophony,  or  increased  bronchial  whisper,  these 
latter  signs  existing  in  close  proximity,  and  representing 
solidification  of  lung  in  the  immediate  neighborhood  of 
the  cavity.  The  diagnostic  application  of  this  sign  is 
chiefly  to  advanced  phthisis. 

Pectoriloquy. — In  pectoriloquy,  not  merely  the  voice, 
but  the  speech,  is  transmitted  through  the  chest;  the 
auscultator  recognizes  words  uttered  by  the  patient. 
The  student,  however,  must  not  expect  to  be  able  to 
carry  on  a  conversation  with  the  patient  by  means  of  the 
stethoscope.  Often  single  words  only  can  be  recognized. 
To  make  sure  that  these  are  transmitted  through  the 
chest,  care  must  be  taken  to  exclude  their  direct  trans- 
mission from  the  patient's  mouth,  and  the  auscultator 
should  not  know  beforehand  the  words  which  are  to  be 
spoken.  If  these  rules  be  not  observed,  the  auscultator 
may  err  in  supposing  that  the  words  are  transmitted 


130  AUSCULTATION    IN    DISEASE. 

through  the  chest.  When  auscultation  is  practiced  with 
one  ear,  the  other  should  be  closed. 

Tiie  speech  with  either  the  loud  or  the  whispered  voice 
may  be  transmitted,  the  latter,  distinguished  as  whisper- 
ing pectoriloquy,  being  much  more  frequent  than  the 
former;  moreover,  in  determining  whispering  pectorilo- 
quy, there  is  less  liability  to  error  in  mistaking  the  per- 
ception of  words  coming  directly  from  the  mouth  for  the 
transmission  through  the  chest.  In  the  production  of 
this  sign,  much  depends  on  the  distinctness  with  which 
words  are  articulated  by  the  patient.  Normal  pectorilo- 
quy at  the  anterior  superior  portion  of  the  chest  is  some- 
times observed. 

Pectoriloquy  belongs  among  the  cavernous  signs  ;  but 
it  is  by  no  means  exclusively  the  sign  of  a  cavity;  the 
speech  may  also  be  transmitted  by  solidified  lung.  It  is 
easy  to  determine  in  any  case  whether  the  sign  denotes 
a  cavity  or  solidified  lung.  If,  with  transmitted  speech, 
the  voice  have  the  characters  of  bronchophony,  the  sign 
represents  solidification  of  lung;  if,  on  the  other  hand, 
the  characters  of  bronchophony  be  wanting,  the  sign 
represents  a  cavity.  These  statements  apply  equally  to 
the  loud  and  to  the  whispered  voice.  Of  course,  asso- 
ciated signs  will  be  likely  to  show  whether  a  cavity  exists 
or  not.  It  is  to  be  added  that  a  cavity  and  solidification 
of  lung  existing  together,  may  conjointly  be  concerned 
in  the  production  of  the  sign. 

Amphoric  Voice  or  Echo. — This  sign  is  identical  in 
character  with  am])horic  respiration,  with  which  it  is 
usually  associated  {vide  page  100).  The  am])horic  into- 
nation may  accompany  the  loud  voice  and  the  whisper; 
generally,  it  is  more  appreciable  or  marked  with  the 
latter.     Its  significance  is  the  same  as  that  of  amphoric 


DIMINISHED    VOCAL    RESONANCE.  131 

respiration.  As  a  rule,  it  rcj)rescnts  the  conditions  in 
pnenmothorax,  namely,  a  large  space  filled  with  air  and 
perforation  of  hint^.  In  this  affection  it  is  associated 
with  other  signs  which  suffice  for  a  prompt  and  positive 
diagnosis.  It  is  not  invariably  fonnd  in  pneumothorax, 
and  it  may  be  present  in  a  case  at  one  time  and  wanting 
at  another  time,  its  production  being  dependent  on  the 
perforation  being  above  the  level  of  liquid,  if  the  latter 
exist,  and  on  the  bronchial  tubes  leading  to  the  perfo- 
ration being  unobstructed.  When  not  associated  with 
other  signs  which  are  diagnostic  of  pnenmothorax,  or 
pneumo-hydrothorax,  it  denotes  a  phthisical  cavity  of 
considerable  size.  It  is  not  infrequently  a  sign  of  a 
phthisical  cavity  with  rigid  walls  and  communicating 
freely  with  bronchial  tubes.  It  has  this  significance 
whenever  pneumothorax  can  be  excluded;  and  the  asso- 
ciated signs  in  the  latter  affection  are  such  that  its  ex- 
clusion is  always  practicable. 

The  amphoric  sound  sometimes  is  observed  to  follow 
the  oral  voice;  hence,  the  name  amphoric  echo. 

Diminished  and  Suppressed  Vocal  Resonance. — 
Diminution  and  suppression  of  the  normal  vocal  reso- 
nance occur  especially  when  the  pleural  cavity  contains 
either  liquid  or  air.  Whenever  the  lungs  are  not  in  con- 
tact with  the  walls  of  the  chest,  the  vocal  resonance,  as 
a  rule,  is  either  notably  lessened  or  wanting:.  The  si<rn 
is,  therefore,  of  value  in  diagnosis  in  cases  of  pleurisy 
with  effusion, empyema,  hydrothorax,and  pneumothorax. 
When  the  pleural  cavity  is  partially  filled  with  liquid, 
there  is  diminution  or  suppression  of  the  resonance  from 
the  level  of  the  liquid  downward;  and  generally,  just 
above  the  level  of  the  liquid,  tlie  resonance  is  increased, 
owing  to  condensation  of  the  lung.     The  sign  is   well 


132  AUSCULTATION    IN    DISEASE. 

illustrated  by  the  contrast  in  such  cases  above  and  below 
the  level  of  the  liquid.  As  a  rule,  the  changes  of  the  level 
of  the  liquid  with  changes  in  position  of  the  body,  may 
be  as  well  demonstrated  by  means  of  vocal  resonance  as 
by  percussion.  Exceptionally,  however,  this  rule  is  not 
available. 

The  practical  importance  of  diminished  and  suppressed 
vocal  resonance  relates  chiefly  to  the  diagnosis  of  the 
affections  just  named.  In  this  application,  however,  the 
associated  signs  must  be  taken  into  account.  The  vocal 
resonance  may  be  diminished  or  suppressed  when  the 
lung  is  completely  solidified  in  the  second  stage  of 
pneumonia  ;  also  in  pulmonary  oedema,  and  over  the  site 
of  an  intra-thoracic  tumor. 

If  the  vocal  resonance  be  normal,  that  is,  neither  in- 
creased nor  diminished,  we  are  warranted  in  excluding 
all  the  affections  which  have  been  named  ;  the  excep- 
tional instances  are  so  rare  that,  practically,  they  may  be 
disregarded. 

Diminished  vocal  resonance  maybe  found  over  a  pul- 
monary abscess  before  the  pus  is  evacuated,  and  over  a 
cavity  filled  with  liquid.  The  sign  is  then  limited  to  a 
circumscribed  space.  Obstruction  of  a  bronchial  tube 
diminishes  resonance  in  so  far  as  the  column  of  air  is  a 
medium  for  the  conduction  of  vocal  sound. 

The  normal  disparity  between  the  two  sides  of  the 
chest  is  to  be  borne  in  mind  with  reference  to  diminished 
or  suppressed,  as  well  as  to  increased,  vocal  resonance; 
otherwise  the  relative  feebleness  of  the  resonance  on  the 
left  side  in  health  might  be  considered  to  be  morbid. 
The  normally  greater  resonance  on  the  right  side  ren- 
ders it  easier  to  determine  a  morbid  diminution  on  this 
than  on  the  left  side. 


COUGHING    OR    TUSSIVE    SIGNS.  133 

Diminished  and  Suppressed  Vocal  Fremitus. — This 
tactile  sensation,  which  is  appreciable  in  auscultation, 
as  a  rule,  is,  on  the  one  hand,  increased,  and,  on  the 
other  hand,  diminished  or  suppressed,  under  the  same 
physical  conditions  which  occasion  corresponding  modifi- 
cations of  the  vocal  resonance.  Diminished  or  sup- 
pressed vocal  fremitus,  therefore,  has  the  same  diagnostic 
significance  as  diminished  or  suppressed  vocal  resonance. 
Usually  the  abnormal  modifications  of  resonance  and 
fremitus  go  together,  but  either  may  be  out  of  proportion 
to  the  other.  Thesio;ns  relatincrto  fremitus  thus  corrob- 
orate  those  relating  to  resonance.  The  former  may  be 
marked  when  the  latter  admit  of  doubt.  Diminished  or 
suppressed  fremitus  is  valuable  in  the  diagnosis  of  pleu- 
risy with  effusion,  empyema,  hydrothorax,  and  pneumo- 
thorax. It  is,  however,  to  be  noted  that  in  exceptional 
instances,  the  fremitus  persists  over  the  site  of  liquid 
within  the  chest. 

With  regard  to  vocal  fremitus,  as  to  vocal  resonance, 
it  is  essential  to  take  cognizance  of  the  normal  disparity 
between  the  two  sides  of  the  chest,  the  greater  rela- 
tive fremitus,  on  the  right  side,  as  a  rule,  being  no  less 
marked  than  the  relatively  greater  resonance  on  that  side. 

Iletalllc  Tinkling. — This  sign  has  the  same  characters 
when  it  accompanies  either  the  loud  or  whispered  voice, 
as  Vvheu  it  is  heard  with  respiration,  and,  of  course,  it 
has  the  same  significance  (vide  page  SQ).  It  may  be  more 
marked  with  acts  of  speaking  than  with  the  respiratory 
acts. 

Signs  obtained  by  Acts  of  Coughing  or  Tussive  Signs. 

Acts  of  coughing  may  be  made  subservient  to  auscul- 
tation of  respiratory  sounds  in  two  ways :  First,  by  the 

12 


134  AUSCULTATION    IN    DISEASE. 

removal  of  temporary  obstruction  from  the  accumulation 
of  mucus  within  bronchial  tubes.  If  the  respiratory 
murmur  be  diminished  or  suppressed  over  a  portion  or 
the  whole  of  one  side  of  the  cliest,  sometimes  an  act  of 
coughing  effects  dislodgment  of  a  mass  of  mucus  from 
either  a  primary  broncluis  or  one  of  its  subdivisions,  and 
the  normal  murnuu' is  at  once  restored.  The  dependence 
of  the  morbid  sign  upon  a  temporary  obstruction  is  thus 
demonstrated.  Second,  by  an  act  of  coughing  more  air 
is  expelled  than  by  an  ordinary  expiration,  and  in  the 
following  inspiration  the  vesicles  have  a  wider  range  of 
expansion,  giving  rise  to  a  proportionately  loud  inspira- 
tory sound ;  hence,  the  characters  of  this  sound  are  more 
pronounced  and  can  be  l)etter  studied.  For  these  two 
objects  it  is  often  advisable  to  request  the  patient  to 
cough  with  a  certain  degree  of  force. 

Acts  of  coughing,  moreover,  give  rise  to  auscultatory 
signs  which  have  their  analogues  in  signs  obtained  by 
respiration  and  the  voice.  These  tussive  signs  are  of 
less  value  than  the  respiratory  and  vocal  signs,  and  in 
most  cases,  owing  to  the  latter  being  sufficient  for  diag- 
nosis, they  may  be  said  to  be  superfluous ;  nevertheless, 
they  may  be  observed  sometimes  with  advantage.  When 
the  conditions  are  present  which  are  represented  by 
bronchial  respiration,  bronchophony  and  the  broncho- 
phonic  whisper,  sounds  are  obtained  which  correspond  to 
these  in  their  characters.  The  cough  is  then  said  to  be 
bronchial.  With  the  stethoscope  applied  over  an  empty 
cavity  of  some  size,  situated  near  the  surface  of  the  lung, 
the  ear  receives  with  acts  of  coughing  a  concussion  or 
shock  which  is  sometimes  so  forcible  as  to  be  painful. 
This  corresponds  to  an  intense  vocal  resonance.  Limited 
to   a   circumscribed    space,   it    is    a    highly    significant 


COUGHING    OR    TUSSIVE    SIGNS.  135 

cavernous  sign.  It  may  be  present  when  the  cavernoiis 
respiration  is  wanting.  A  low-pitched  blowing  sound 
corresponds  to  the  expiratory  sound  in  the  cavernous 
respiration  and  the  cavernous  whisper.  An  amphoric 
intonation  may  be  heard  with  acts  of  coughing,  which 
corresponds  to  amphoric  respiration  and  amphoric  voice. 
This  sign  is  sometimes  more  marked  with  cough  than 
with  the  breathing  and  voice.  Cavernous  gurgling  may 
also  be  obtained  more  distinctly  with  cough  than  with 
respiration.  Finally,  metallic  tinkling  not  infrequently 
accompanies  acts  of  coughing. 


136  PHYSICAL    DIAGNOSIS. 


CHAPTER   yi. 

THE   PHYSICAL   DIAGNOSIS   OF   DISEASES   OF   THE 
EESPIRATORY    ORGANS. 

Affections  of  the  larynx  and  trachea — Bronchitis  seated  in  large  hron- 
chial  tubes — Bronchitis  seated  in  small  bronchial  tubes,  or  capillary 
bronchitis — Collapse  of  pulmonary  lobules — Lobular  pneumonia — 
Asthma — Pulmonary  or  vesicular  emphysema — Pleurisy,  acute  and 
chronic  —  Empyema  —  Hydrothorax  —  Pneumothorax  —  Pneumo- 
hydrothorax  —  Pneumo-pyothorax  —  Acute  lobar  pneumonia — Cir- 
cumscribed pneumonia — Embolic  pneumonia — Hsemorrhagic  infsirc- 
tus  —  Pulmonary  apoplexy  —  Pulmonary  gangrene  —  Pulmonary 
oedema  —  Carcint/ma  of  lung  —  Tumor  within  the  chest  —  Acute 
miliary  tuberculosis — Pulmonary  phthisis — Fibroid  phthisis,  inter- 
stitial pneumonia,  or  cirrhosis  of  lung — Diaphragmatic  hernia. 

In  the  preceding  chapters  the  physical  conditions 
incident  to  the  morbid  changes  occnrring  in  the  affections 
of  the  respiratory  organs  hav^e  been  enumerated,  and 
the  physical  signs,  obtained  by  percussion  and  ausculta- 
tion, representing  these  conditions,  have  been  considered, 
severally,  as  regards  their  distinctiv^e  characters  and  their 
significance.  The  object  of  this  chapter  is  to  group  the 
physical  conditions  embraced  in  the  different  diseases  of 
the  respiratory  system  respectively,  together  with  the 
representative  signs  on  which  rests  the  physical  diagnosis 
of  each  of  the  diseases.  The  scope  of  this  manual  is 
limited  to  the  physical  diagnosis  of  these  affections;  but 
the  fact  is  not  to  be  lost  sight  of  that  in  practical  medi- 
cine physical  signs  are  not  to  be  disassociated  from  symp- 
toms and  pathological  laws.  An  exclusive  reliance  on 
physical  signs  would  lead  to  errors  in  diagnosis,  although, 


AFFECTIONS    OF    TUE    LARYNX    AND    TRACHEA.    137 

doubtless,  errors  more  important  and  more  frequent 
necessarily  occur  when  the  practitioner  ignores  percus- 
sion and  auscultation.  The  signs  furnished  by  percus- 
sion and  auscultation  only  have  been  thus  far  considered, 
but  in  grouping  these  in  this  chapter,  signs  obtained  by 
other  methods  of  physical  exploration  will  be  embraced 
in  so  far  as  they  enter  into  the  diagnosis  of  the  different 
diseases  of  the  respiratory  system.  These  different  dis- 
eases will  be  taken  up  separately  with  the  exception  of 
those  seated  in  the  larynx  and  trachea.  With  reference 
to  physical  signs,  the  laryngeal  and  tracheal  aifections 
may  be  considered  collectively. 

Affections  of  the  Larynx  and  Trachea. 

The  physical  signs  referable  to  the  chest  in  diseases  of 
the  larynx  and  trachea,  denote  more  or  less  obstruction 
to  the  free  passage  of  air  through  these  sections  of  the 
air-tubes.  The  obstruction  in  the  different  diseases  in- 
volves different  pathological  conditions.  Spasm  of  the 
glottis  is  one  of  these  conditions,  constituting  the  affec- 
tions known  as  laryngismus  stridulus  and  spasmodic 
croup,  occurring  also  as  a  pathological  element  in  laryn- 
gitis, and  sometimes  in  connection  Avith  aneurism,  or  a 
tumor  of  some  kind,  involving  the  recurrent  laryngeal 
nerve.  Another  pathological  condition  is  the  opposite  of 
this,  namely,  paralysis  of  the  muscles  of  the  glottis,  the 
vocal  chords  remaining  flaccid,  and  approximating  during 
inspiration.  Other  pathological  conditions  are,  oedema 
of  the  glottis,  swelling  of  the  membrane  at  the  glottis  in 
laryngitis,  together  with,  in  the  adult,  submucous  infil- 
tration, diphtheritic  exudation,  cicatrization  of  ulcers, 
morbid  growths,  and  the  presence  of  foreign  bodies. 


138  PHYSICAL    DIAGNOSIS. 

In  the  affections  inv^olving  the  foregoing  pathological 
conditions,  percussion  and  auscultation  are  of  use,  first^ 
by  enabling  the  physician  to  exclude  all  diseases  within 
the  chest.  The  absence  of  signs  showing  the  existence 
of  pulmonary  diseases  renders  it  certain  that  the  symp- 
toms denoting  embarrassment  of  respiration  are  referable 
to  the  larynx  or  trachea.  Second,  by  means  of  auscul- 
tation the  amount  of  obstruction  may  be  determined 
more  accurately  than  by  the  subjective  symptoms.  The 
amount  of  obstruction  is  represented  by  a  proportionate 
weakenino;  of  the  vesicular  murmur.  This  is  more 
reliable  as  regards  determining  a  dangerous  amount  of 
obstruction  than  the  sense  of  the  want  of  air  or  the  suf- 
fering of  the  patient.  The  degree  of  diminution  of  the 
vesicular  murmur  is  determinable  with  the  more  accuracy 
the  better  the  auscultator  is  acquainted  with  the  normal 
intensity,  that  is,  the  intensity  prior  to  the  occurrence  of 
obstruction.  With  this  knowledge,  the  weakening  of  the 
murmur  is  a  correct  criterion  of  the  amount  of  obstruc- 
tion. In  all  the  pathological  conditions  named,  the 
respiratory  murmur  is  more  or  less  diminished  in  in- 
tensity on  both  sides  of  the  chest ;  there  are  no  signs 
obtiiined  by  percussion,  nor  do  vocal  resonance  or  frem- 
itus offer  anything  distinctive. 

In  cases  of  considerable  or  great  obstruction  during 
inspiration,  inspection  furnishes  marked  signs.  The  ex- 
pansion of  the  chest  on  boUi  sides  is  restricted,  the  lower 
part  of  the  chest  is  contracted  in  the  act  of  inspiration, 
and  in  this  act  the  soft  parts  above  the  clavicles  are  de- 
pressed. The  contrast  between  these  abnormal  move- 
ments and  the  normal  thoracic  movements  of  the  patient 
is  striking  and  distinctive. 

An  important  application  of  auscultation  is  the  localiz- 


BRONCHITIS  IN  LARGE  BRONCHIAL  TUBES.   139 

ation  of  a  foreign  body  which  has  been  inhaled.  If  the 
vesicular  murmur  on  both  sides  be  more  or  less  weak- 
ened, the  foreign  body  must  be  situated  in  either  the 
larynx  or  the  trachea.  If,  on  the  other  hand,  the  vesicu- 
lar murmur  be  weakened  or  suppressed  on  one  side,  and 
increased  on  the  other  side,  the  body  is  lodged  in  a 
primary  bronchus.  The  importance  of  this  application 
of  auscultation  before  opening  the  trachea  to  remove  a 
foreign  body  is  sufficiently  obvious.  The  situation  of  a 
foreign  body  may  be  changed  from  one  bronchus  to  the 
other  by  an  act  of  coughing,  even  after  an  operation  has 
been  commenced  ;  this  is,  of  course,  at  once  determinable 
by  auscultation. 

Bronchitis  Seated  in  Large  Bronchial  Tubes. 

In  bronchitis,  either  acute  or  chronic,  as  it  is  ordinarily 
presented  in  practice,  the  inflammation  is  seated  in  the 
large  bronchial  tubes,  in  many  cases  probably  not  ex- 
tending beyond  the  primary  bronchi.  The  physical 
conditions  are,  more  or  less  swelling  of  the  mucous 
membrane,  this,  however,  not  being  sufficient  to  occasion 
any  notable  obstruction  to  the  free  passage  of  air,  and 
the  presence,  in  different  cases,  in  greater  or  less  quan- 
tity, of  mucus,  muco-purulent  matter,  pure  pus,  and 
serum. 

The  physical  diagnosis  involves  negative  rather  than 
])ositive  points;  in  other  words,  the  diseases  from  which 
bronchitis  is  to  be  differentiated  are  excluded  by  the 
absence  of  their  diagnostic  signs.  These  diseases  are 
pneumonia,  pleurisy,  and  phthisis.  Each  of  these  is 
characterized  by  the  presence  of  signs,  the  absence  of 
which  warrants  its  exclusion.  In  bronchitis  there  is  no 
disparity  between    the    two    sides  of  the  chest  in  the 


140  PHYSICAL    DIAGNOSIS. 

resonance  obtained  by  percussion,  nor  in  vocal  resonance, 
the  bronchial  whisper,  and  fremitus.  The  swelling  of 
the  bronchial  mucous  membrane  may  cause  some  diminu- 
tion of  the  intensity  of  the  vesicular  murmur,  but  as 
the  affection  is  bilateral,  and  the  bronchial  tubes  on  each 
side  are  affected  equally,  both  in  degree  and  extent,  no 
appreciable  disparity  in  this  respect  between  the  two 
sides  is  caused  by  this  physical  condition.  Weakening 
or  suppression  of  the  murmur  over  an  area  greater  or 
less,  may  be  caused  by  bronchial  obstruction  from  a 
plug  of  mucus.  This  obstruction  is  sometimes  removed 
by  an  act  of  expectoration,  after  which  the  murmur  is 
found  to  have  returned,  or  to  have  regained  its  normal 
intensity. 

The  foregoing  points,  taken  in  connection  with  the 
history  and  symptoms,  suffice  for  the  diagnosis.  Signs 
due  directly  to  the  disease  represent  diminished  calibre 
of  the  tubes  at  certain  points  from  swelling  of  the  mem- 
brane, adhesive  mucus,  and  spasm  of  bronchial  muscular 
fibres.  These  signs  are  the  dry  bronchial  rales.  They 
are  rarely  prominent,  and  are  oftener  absent  than  pres- 
ent, if  the  bronchitis  be  unaccompanied  by  asthma; 
hence,  they  are  of  little  value  in  the  diagnosis.  Other 
signs  are  the  bubbling  sounds  or  the  moist  bronchial 
rales.  In  acute  bronchitis,  these  are  oftener  absent  than 
present.  They  occur  when  liquid  morbid  products  with- 
in the  tubes  are  unusually  abundant,  or  when  the  removal 
of  these  is  with  difficulty  effected  by  expectoration  in 
consequence  of  muscular  debility  or  other  causes.  These 
rales  are  abundant  and  loud  in  proportion  as  the  liquid 
within  the  tubes  is  either  muco-j)urulent,  purulent,  or 
serous  in    character.     They  are  more  or  less  coarse  in 


CAPILLARY    BRONCHITIS.  141 

proportion  to  the  size  of  the  tubes  in  which  the  bubbling 
takes  place. 

The  diagnostic  points,  negative  and  positive,  which 
have  been  stated,  are  alike  applicable  to  acute  and 
chronic  bronchitis,  it  being,  of  course,  understood  that 
the  atfection  is  primary,  that  is,  not  secondary  to  some 
other  pulmonary  disease. 

Bronchitis  Seated  in  Small  Bronchial  Tubes — Capillary- 
Bronchitis — Collapse  of  Pulmonary  Lobules — Lobular 
Pneumonia. 

Inflammation  extending  into  the  small  tubes  (capillary 
bronchitis)  occasions  in  these  the  same  physical  condi- 
tions which  are  incident  to  bronchitis  aifectino-  tubes  of 
large  size,  namely,  swelling  of  the  membrane,  and  the 
presence  of  liquid  morbid  products.  The  latter  are  not 
as  easily  removed  by  expectoration  as  when  they  are 
within  large  tubes,  and,  therefore,  they  are  constantly 
present  in  greater  or  less  quantity.  These  conditions  in 
small  tubes  involve  obstruction  to  the  free  passage  of  air 
to  and  from  the  air-vesicles;  hence,  the  vast  difference 
as  regards  the  symptoms,  the  suffering,  and  the  danger. 
The  affection  is  bilateral,  a  fact  greatly  enhancing  the 
gravity  of  the  affection.  An  incidental  physical  condi- 
tion.is  solidification,  generally  in  disseminated  portions  of 
lung,  the  latter  varying  in  number  and  size.  These  por- 
tions of  solidified  lung  denote  either  collapse  of  pulmo- 
nary lobules  or  lobular  pneumonia,  or  both  in  conjunction. 
To  this  incidental  affection,  German  writers  apply  the 
name  "Catarrhal  pneumonia."  Of  course,  any  discus- 
sion of  pathological  questions  suggested  by  these  names 
would  be  here  out  of  place.  With  reference  to  diagnosis 
it  is  to  be  borne  in   mind  that  the  solidified  portions  of 


112  PHYSICAL    DIAGNOSIS. 

liin^  in  cases  of  bronchitis  seated  in  small  tubes  are  espe- 
cially situated  in  the  lower  lobes.  Another  incidental 
physical  condition  is  temporary  dilatation  of  the  air-cells, 
or  vesicular  emphysema,  seated  in  the  upper  lobes.  Both 
of  these  incidental  conditions  are  bilateral,  like  the  bron- 
chitis with  which  they  are  connected.  Collapse  of  pul- 
monary lobules,  or  lobular  pneumonia,  or  both,  and 
emphysema  occur  in  only  a  certain  proportion  of  the 
cases  of  bronchitis  seated  in  small  tubes.  The  signs, 
therefore,  admit  of  a  division  into  those  which  relate, 
]st,  to  the  bronchitis,  and,  2d,  to  these  incidental  affec- 
tions. With  reference  to  the  diagnosis,  the  fact  is  to  be 
borne  in  mind  that  bronchitis  seated  in  small  tubes  occurs 
chiefly  in  children  and  the  aged. 

The  physical  diagnosis  of  bronchitis  seated  in  small 
tubes,  rests  on  negative  points,  together  with  a  positive 
sign  which  is  uniformly  present.  This  sign  is  the  fine 
moist  bronchial  or  subcrepitant  rale,  present  on  both 
sides  and  diffused  over  the  chest.  The  bubbling  sounds 
are  to  be  distinguished  from  the  fine  dry  crackling  sounds 
or  the  crepitant  rale,  to  the  characters  of  which  the 
former  in  some  measure  approximate. 

The  bronchitis  gives  rise  neither  to  dulnesson  percus- 
sion, nor  to  any  notable  change  in  vocal  resonance,  or 
fremitus.  The  respiratory  murmur,  if  not  obscured  by 
rales,  is  weakened  on  both  sides.  Irrespective  of  being 
drowned  by  rales,  it  may  be  suppressed  by  the  amount 
of  bronchial  obstruction.  These  are  the  negative  points 
in  the  diagnosis.  In  pulmonary  oedema,  fine  moist 
bronchial  rales  are  present  on  both  sides,  but  in  this 
affection  there  is  notable  dulness  on  percussion,  and  the 
affection  occurs  in  certain  pathological  connections, 
namely,  with  mitral  stenosis,  and  disease  of  the  kidneys. 


LOBULAR    PNEUMONIA.  143 

Acute  tuberculosis  may  present  the  moist  bronchial  rales 
with  the  negative  points  which,  in  connection  with  symp- 
toms, characterize  bronchitis  seated  in  the  small  tul)es. 
The  differentiation  is  to  be  based  on  difFerences  pertaining 
to  the  history  and  duration,  together  with  the  age  of  tlie 
patient. 

The  coexistence  of  the  incidental  affections,  namely, 
collapse  of  pulmonary  lobules,  or  lobular  pneumonia,  and 
vicarious  emphysema,  occasions  additional  signs.  If  the 
solidified  portions  of  king  be  considerable  in  either  num- 
ber or  size,  there  will  be  dulness  on  percussion  in  circum- 
scribed situations  on  the  posterior  aspect  of  the  chest. 
This  will  be  found  on  both  sides,  but  perhaps  more 
marked  on  one  side.  Broncho-vesicular  or  the  bronchial 
respiration  may  be  present,  together  witli  the  vocal  signs 
of  solidification,  namely,  either  increased  vocal  resonance, 
or  bronchoj)hony,  and  increased  vocal  fremitus.  The 
moist  rales  produced  within  solidified  portions  of  lung 
are  higli  in  pitch,  wliereas,  if  solidification  do  not  exist, 
these  rales  are  comparatively  low  in  pitch.  The  exist- 
ence of  solidification  at  any  point  may  be  determined  by 
the  pitch  of  the  rales,  as  well  as  by  the  foregoing  respi- 
ratory and  vocal  signs. 

When  there  are  emphysematous  lobules  on  the  ante- 
rior aspect  of  the  chest  in  the  upper  and  middle  regions, 
on  both  sides,  the  resonance  on  percussion  is  vesiculo-tym- 
])anitic,  the  respiratory  murmur  weakened  or  suppressed, 
and  the  rhythm  altered — in  short,  the  combination  of 
signs  which  will  be  stated  under  the  head  of  emphysema. 

In  the  cases  in  which  the  bronchitis  occasions  great  ob- 
struction in  the  small  tubes,  and,  still  more,  if  collapse  of 
lobules,  or  lobular  pneumonia  and  vicarious  emphysema 
occur,  important  signs  are  obtained  by  inspection.     Tlie 


144  PHYSICAL    DIAGNOSIS. 

anterior  portion  of  the  chest  remains  expanded,  and  re- 
traction of  the  lower  part  of  the  chest  takes  place  in  the 
acts  of  inspiration. 

Asthma. 

The  pathologico-physical  condition  in  a  paroxysm  of 
asthma,  is  obstrnction  in  the  small  bronchial  tnbes 
attributable  to  spasm  of  the  bronchial  muscular  fibres. 
AVith  thii^  condition  is  associated  a  temporary  vesicular 
emphysema,  which  exists  often  as  a  persistent  aflTection 
in  persons  who  are  subject  to  asthma.  If  the  emphy- 
sematous condition  already  exist,  it  is  increased  during 
the  paroxysm  of  asthma.  Bronchitis  generally  coexists 
either  as  a  transient  or  a  chronic  affection.  In  an 
asthmatic  paroxysm,  therefore,  there  are  present  the 
signs  which  are  proper  to  asthma,  together  with  those  of 
emphysema,  and  the  associated  bronchitis  may  also  oc- 
casion additional  signs. 

The  physical  diagnosis  of  asthma,  like  that  of  bron- 
chitis seated  in  small  tubes,  is  based  on  negative  points 
taken  in  connection  with  a  sign  which  is  invariably 
present,  namely,  dry  bronchial  rales.  These  rales  are 
more  or  less  intense,  and  they  are  diffused  over  the 
entire  chest.  They  are  generally  heard  at  a  distance. 
The  sibilant  and  sonorous  varieties  are  mingled,  and 
they  are  constantly  changing  as  regards  the  character  of 
the  sounds. 

The  negative  points  are  the  same  as  in  capillary 
bronchitis,  namely,  absence  of  dulness  on  percussion, 
vocal  resonance  and  fremitus  also  being  unaltered. 
Asthma  and  bronchitis  seated  in  small  tubes  agree  in  the 
fact  that  obstruction  is  the  important  physical  condition. 
A  highly  important  differential  point  relates  to  the  fre- 


PULMONARY    OR    VESICULAR    EMPHYSEMA.      145 

quency  of  the  respirations;  they  are  much  increased  in 
frequency  in  capillary  bronchitis  and  not  in  asthma.  Pa- 
thologically they  differ  essentially  in  tiie  fact  that  the 
obstruction  is  due  in  the  latter  affection  to  bronchial  in- 
flammation, and  in  the  former  to  spasm.  The  two  affec- 
tions differ  in  the  signs  representing  these  different  con- 
ditions, fine  moist  bronchial  rales  existing  in  one,  and 
loud  diffused  dry  bronchial  rales  existing  in  the  other. 

Taking  the  difference  as  regards  the  positive  physical 
signs  in  connection  with  the  history  and  symptoms,  the 
differentiation  of  the  two  affections  may  be  made  without 
difficulty. 

The  signs  which  relate  to  the  associated  emphysema- 
tous condition,  are  those  which  are  diagnostic  of  this 
condition  existing  irrespective  of  asthma;  and  the  phys- 
ical diagnosis  of  emphysema  will  be  next  considered. 
Coexisting  bronchitis  may  give  rise  to  moist  bronchial 
rales  more  or  less  coarse.  These  are,  however,  often 
wanting,  and  they  are  rarely  marked  during  paroxysms 
of  asthma.  AVhen  present  in  this  pathological  connec- 
tion, they  are  low  in  pitch,  denoting  the  absence  of 
solidification  of  lung. 

Pulmonary  or  Vesicular  Emphysema. 

This  affection,  as  a  rule,  is  seated  exclusively  or  chiefly 
in  the  upper  lobes.  When  it  is  lobar,  in  contradistinc- 
tion from  the  emphysema  existing  in  comparatively  a  few 
disseminated  or  isolated  portions  of  lung,  increase  in  vol- 
ume of  the  affected  lobes  is  an  important  physical  condi- 
tion standing  in  relation  to  certain  signs.  Diminished 
range  of  expansion  with  acts  of  inspiration  is  another 
physical  condition ;  the  affected  lobes  arc  in  a  permanent 
state  of  expansion  approximating  to  that  at  the  end  of  the 


146  PHYSICAL    DIAGNOSIS. 

inspiratory  act.  It  follows  from  these  conditions  that  the 
amount  of  air  is  in  excess  of  the  normal  proportion  to 
the  solids  and  liquids  in  the  affected  lobes.  Both  lungs 
are  affected,  that  is,  the  affection  is  bilateral.  In  the 
great  majority  of  cases  chronic  bronchitis  coexists,  and 
patients  affected  with  emphysema  are  often,  but  by  no 
means  invariably,  subject  to  paroxysms  of  asthma.  Not 
infrequently  an  asthmatic  element,  WMth  or  without  pro- 
nounced paroxysms  of  asthma,  exists  much  of  the  time 
in  connection  with  emphysema.  The  emphysematous 
condition,  as  a  rule,  with  few  exceptions,  is  greater  in 
the  upper  lobe  of  the  left  than  of  the  right  lung.  A  rare 
condition,  which  is  generally  included  under  the  name 
emphysema,  differs  materially  from  the  ordinary  form  of 
this  affection.  This  condition  is  that  also  known  as 
senile  atrophy  of  the  lungs.  The  volume  of  the  lungs 
is  not  increased  in  this  variety  of  emphysema,  the  pro- 
portion of  air  over  the  solids  is,  however,  in  excess, 
owing  to  the  diminution  of  the  latter  from  atrophy. 

The  diagnostic  evidence  obtained  by  percussion  is 
quite  distinctive  of  lobar  emphysema.  The  resonance 
over  the  upper  and  middle  regions  of  the  chest  on  both 
sides  is  vesiculo-tympanitic,  that  is,  the  intensity  of  the 
resonance  is  abnormally  increased,  the  quality  is  a  com- 
bination of  the  vesicular  and  tympanitic,  and  the  pitch 
is  more  or  less  raised.  Owing  to  the  fact  that  the  em- 
physema is  greater  on  the  left  than  on  the  right  side, 
the  vesiculo-tympanitic  resonance  is  more  marked  on  the 
left  side.  The  difference  in  intensity  between  the  two 
sides  may  load  to  the  error  of  regarding  the  resonance 
on  the  right  side  as  dulness.  The  error  is  avoided  by 
attention  to  the  pitch  and  the  quality  of  the  resonance. 
If  dulness  existed  on   the  right  side,  the  pitch  of  the 


PULMONARY    OR    VESICULAR    EMPHYSEMA.       147 

sound  should  be  higher  on  that  side;  on  the  other  hand, 
if  tlie  difference  in  intensity  be  due  to  the  greater  amount 
of  emphysema  on  the  left  side,  the  pitch  is  Iiigher  on 
that  side,  and  the  quality  vesiculo-tympanitic.  The 
attention  of  the  student  is  particularly  called  to  the  fore- 
going points  of  distinction.  Assuming  that  a  vesiculo- 
tympanitic resonance  exists  anteriorly  on  both  sides,  and 
that  it  is  marked  on  the  left  as  contrasted  with  the  right 
side,  how  is  the  existence  of  this  sign  on  the  right  side 
to  be  determined  ?  The  answer  is,  the  resonance  over 
the  upper  is  to  be  com])nred  with  that  over  the  lower 
lobe  of  the  right  lung.  Percussing  first  over  tiie  upper 
lobe  of  the  right  lung,  and  second  over  the  lower  lobe 
of  this  lung,  that  is,  posteriorly,  below  the  scapula,  or 
in  the  infra-axillary  region,  the  vesiculo-tym})anitic  reso- 
nance over  the  upper  lobe  is  rendered  manifest.  In  a 
series  of  patients  affected  with  emphysema,  the  uniformity 
of  the  results  of  percussion  is  very  striking;  anteriorly, 
over  the  left  side,  the  resonance  is  vesiculo-tympanitic 
as  compared  with  the  resonance  on  the  right  side,  and 
the  resonance  is  shown  to  be  vesiculo-tympanitic  on  the 
right  side  anteriorly  as  compared  with  the  resonance 
posteriorly  below  the  scapula. 

As  regards  the  abnormal  modifications  of  the  respira- 
tory murmur  in  emphysema,  there  is,  first,  either  weak- 
ened respiratory  murmur  without  notable  change  in  pitch 
or  quality,  or  suppression  of  the  murmur.  Diminished 
intensity  of  the  murmur  exists  over  the  upper  lobes  on 
both  sides,  as  compared  with  the  murmur  over  the  lower 
lobes;  and  in  most  cases  the  greater  diminution  or  the 
suppression  is  on  the  left  rather  than  on  the  right  side. 
Exceptions  to  the  latter  statement  may  be  caused  by 
obstruction  of  the  bronchial  tubes  on  the  right,  and  not 


148  PHYSICAL    DIAGNOSIS. 

on  the  left  side  by  an  accumulation  of  mucus,  and,  in 
rare  instances,  by  the  fact  that  the  emphysema  is  greater 
on  the  right  side.  Occasionally  there  is  almost  suppres- 
sion below  with  preserved  respiration  above  of  the  em- 
physematous type,  and  this  so  continuous  as  not  to  be 
explained  by  obstruction  of  tubes.  Second,  modifications 
in  rhythm  are  not  infrequent.  These  consist  in  a  short- 
ened (deferred)  inspiratory,  and  a  prolonged  expiratory 
sound.  In  some  instances  an  inspiratory  sound  is  want- 
ing, and  an  ex})iratory  sound  is  alone  heard.  The  pro- 
longed expiratory  sound  in  emphysema  is  always  low  in 
pitch  and  blowing  or  non-tubular  in  quality,  in  these  re- 
spects differing  from  the  prolonged  expiration  which 
denotes  solidification  of  lung,  the  latter  being  high  in 
pitch  and  tubular  in  quality.  These  essential  points  of 
difference  I  claim  to  have  been  the  first  to  have  dis- 
tinctly stated. 

The  foregoing  signs  obtained  by  percussion  and  aus- 
cultation are  those  which  are  in  a  positive  sense  diagnostic 
of  emphysema.  Associated  with  these  are  certain  im- 
portant negative  points,  as  follows:  vocal  resonance, 
vocal  fremitus,  and  bronchial  whis})er  are  not  notably 
altered.  These  negative  points  suffice  to  exclude  other 
affections  than  emphysema. 

Signs  obtained  by  inspection  are  quite  distinctive  of 
this  affection.  Emphysema,  existing  in  a  marked  degree, 
causes  a  characteristic  deformity  of  the  chest;  the  anterior 
surface  is  bulging,  giving  to  the  chest  an  abnormally 
rounded,  bow-windowed,  o^  barrel-shaped  appearance, 
the  lower  part  appearing  to  be  contracted.  This  de- 
formity occurs  when  the  emphysema  has  been  developed 
in  early  life.  The  movements  of  the  chest  in  inspiration 
are  characteristic.     In  tranquil  breathing  there  is  but 


PULMONARY    OR    VESICULAR    EMPHYSEMA.       149 

little  movement  of  the  upper  and  anterior  regions,  but 
in  forced  breathing  tlie  sternum  and  ribs  move  together 
as  if  they  were  one  solid  piece.  The  lower  portion  of 
the  chest  and  the  epigastrium  are  retracted  in  inspira- 
tion ;^  the  costal  angle  is  diminished,  the  ribs  and  carti- 
lages connected  with  the  sternum  being  sometimes  on  a 
line  ;  the  soft  parts  above  the  clavicle  and  sternum  are 
often  notably  depressed  with  inspiration.  Owing  to  de- 
pression of  the  heart  downward  and  inward,  the  cardiac 
impulses  are  seen  and  felt  in  the  epigastrium.  Percus- 
sion and  vocal  resonance,  at  the  same  time,  show  the 
superficial  cardiac  region  to  be  diminished  or  lost,  the 
upper  lobe  of  the  left  lung  covering  this  space.  There 
may  be  more  or  less  anterior  curvature  of  the  spine,  and 
the  lower  portions  of  the  scapulae  may  project,  so  that 
sometimes  the  plane  of  these  bones  is  almost  horizontal. 
These  striking  appearances  characterize  cases  in  which 
emphysema  exists  in  a  marked  degree,  and  especially 
when  the  affection  dates  from  early  life.  They  are  less 
marked  or  wanting  if  the  emphysema  be  moderate  in 
degree,  and  it  have  taken  place  in  middle-aged  persons 
or  those  advanced  in  years. 

In  the  variety  of  emphysema  distinguished  as  senile, 
or  senile  atrophy  of  the  lungs,  in  which  there  is  coales- 
cence of  air-vesicles  from  destruction  of  the  cell-walls 
without  increased  volume  of  the  affected  lobes,  the  dias- 
nosis  is  to  be  based  on  the  vesiculo-tympanitic  resonance 
on  percussion,  weakened  respiratory  murmur,  with,  per- 
haps, the  alterations  in  rhythm,  sinking  of  the  soft  parts 
above  the  clavicles,  and  the  negative  points,  exclusive  of 
deformity  of  the  chest,  which  have  been  described. 

^  The  retraction  may  be  only  apparent.  Professor  Janeway  states 
that  he  has  made  measurements  showing  in  some  cases  that  there  is 
no  real  retraction. 

13 


150  PHYSICAL    DIAGNOSIS. 

Emphysema  can  hardly  be  confounded  with  any  other 
affection  than  phthisis.  The  diiferentiation  between  these 
two  affections  is  sufficiently  easy  if  the  diagnostic  points, 
positive  and  negative,  of  the  former,  be  appreciated. 
Phthisis  occurring  in  a  patient  affected  with  emphysema 
makes  a  somewhat  difficult  problem  in  diagnosis,  but, 
fortunately  for  the  diagnostician,  a  patient  with  emphy- 
sema very  rarely  becomes  phthisical. 

Owing  to  the  frequency  with  which  an  asthmatic  ele- 
ment enters  into  the  clinical  history  of  emphysema,  the 
dry  bronchial  (sibilant  and  sonorous)  rales  are  often  pres- 
ent, even  when  paroxysms  of  asthma  do  not  occur. 

Pleurisy,  Acute  and  Chronic— Empyema — Hydrothorax. 

In  the  first  stage  of  acute  pleurisy,  that  is,  prior  to 
the  effusion  of  liquid,  the  physical  conditions  are,  the 
presence  of  more  or  less  recently  exuded,  soft  lymph 
upon  the  pleural  surfaces,  which  are  now  in  contact,  and 
restrained  movements  of  respiration  on  the  affected  side 
in  consequence  of  the  pain  which  they  occasion.  In  the 
second  stage  serous  liquid  accumulates  within  the  pleural 
cavity,  the  quantity  varying  in  different  cases,  sometimes, 
although  rarely,  filling  the  chest  on  the  affected  side. 
In  proportion  to  the  quantity  of  liquid,  the  space  over 
which  the  pleural  surfaces  are  in  contact  is  restricted, 
the  movements  of  these  surfa(!es  over  each  other  are 
limited,  and  the  lung  is  condensed.  In  the  third  stage 
the  quantity  of  liquid  decreases,  the  space  over  which 
the  pleural  surfaces  are  in  contact  increases,  and  the 
compressed  lung  is  more  or  less  expanded.  The  lymph 
upon  the  pleural  surfaces  becomes  more  dense  and  ad- 
herent. Tlie  surfaces  may  become  agglutinated  by  the 
intervening  lymph.     Finally,  in  convalescence,  perma- 


PLEURISY,    ACUTE    AND    CHRONIC.  151 

nent  adhesions  result  from  the  production  or  growth  of 
areolar  tissue. 

In  subacute  and  chronic  pleurisy  there  is  the  same 
series  of  physical  conditions,  the  points  of  difference 
being,  as  a  rule,  a  less  amount  of  exudation,  and  a  greater 
amount  of  effused  liquid.  The  quantity  of  liquid  in 
chronic  pleurisy,  is  often  sufficient  to  compress  the  lung 
into  a  small  solid  mass,  situated  at  the  upper  and  j)os- 
terior  part  of  the  chest,  and  to  dilate  the  affected  side. 
The  heart  is  often  removed  from  its  normal  situation.  If 
the  pleurisy  be  on  the  left  side  the  heart  may  be  pushed 
laterally  beyond  the  right  margin  of  the  sternum  ;  if  the 
pleurisy  be  on  the  right  side  the  heart  is  pushed  laterally 
to  the  left  of  its  normal  situation. 

In  eraj)yema  the  accumulation  of  pus  is  apt  to  be  still 
greater  than  that  of  serous  effusion  in  simple  chronic 
pleurisy,  causing,  of  course,  greater  dilatation  of  the 
chest,  and  more  displacement  of  the  heart. 

In  these  varieties  of  pleurisy  the  affection,  with  rare 
exceptions,  is  unilateral. 

In  hydrothorax  the  conditions  differ,  first,  as  regards 
the  absence  of  the  exudation  of  lymph;  second,  the  af- 
fection is  bilateral,  the  effusion  of  liquid  taking  place 
in  both  pleural  cavities;  and,  ^/wVcZ,  although  the  quantity 
of  liquid  may  be  considerably  greater  on  one  side,  the  ac- 
cumulation very  rarely,  if  ever,  is  sufficient  to  ca^ise  much 
dilatation  of  the  chest  on  that  side,  with  complete  conden- 
sation of  the  lung,  and  notable  displacement  of  the  heart. 

The  signs  in  the  first  stage  of  acute  pleurisy  are  rela- 
tive feebleness  of  the  respiratory  murmur  on  the  affected 
side,  from  the  restrained  respiratory  movements  on  that 
side,  and  a  rubbing  friction-sound.  The  former  is  not 
distinctive  of  pleurisy,  being  present  when  the  respira- 


152  PHYSICAL    DIAGNOSIS. 

tory  movements  on  one  side  are  restrained  by  pain  in 
intercostal  neuralgia  and  pleurodynia.  A  friction-sound 
is  not  ahvays  obtained.  In  the  absence  of  this  sound 
the  physical  diagnosis  cannot  be  made  with  positiveness 
prior  to  the  effusion  of  liquid.  Assuming  that  the  gen- 
eral and  local  symptoms  ])oint  to  an  acute  inflammatory 
affection,  the  differential  diagnosis  relates  to  pleurisy  and 
pneumonia.  A  pleural  friction-sound  may  be  present  in 
the  latter  as  well  as  the  former  of  these  two  affections. 
The  pathognomonic  sign  of  pneumonia,  the  crepitant  rale, 
being  wanting,  the  differentiation,  in  this  stage,  must 
rest  on  diagnostic  points  pertaining  to  the  symptoms.^ 

In  the  second  stage  of  acute  pleurisy  the  diagnostic 
signs  are  those  which  denote  the  presence  of  liquid 
within  the  pleural  cavity.  These  signs  are  simple  and 
distinctive.  There  is  either  dulness  or  flatness  on  per- 
cussion at  the  base  of  the  chest,  extending  upward  a  dis- 
tance proportionate  to  the  quantity  of  liquid.  If  the 
trunk  be  in  a  vertical  position,  that  is,  the  patient  sitting 
or  standing,  the  line  of  demarcation  between  the  dulness 
or  flatness  and  pulmonary  resonance  is,  or  approximates 
to,  a  horizontal  line  on  the  anterior  aspect  of  the  chest. 
This  line  denotes  the  level  of  the  liquid  and  is  easily 
obtained  by  percussion.  It  is  as  easily  determined  by 
auscultating  the  vocal  resonance,  this  either  abruptly 
ceasing  or  being  notably  diminished  at  the  level  of  the 
liquid.  Having  ascertained  the  line  forming  the  upper 
boundary  of  dulness  or  flatness  on  the  anterior  aspect 
of  the  chest,  the  patient  sitting  or  standing,  if  the  po- 
sition be  changed  to  recumbency  on  the  back,  and  the 

'  Professor  Janeway  states  tliatliehas  sometimes  heard  a  crepitant 
rale  at  the  inception  of  pleurisy,  without  coexistinji:  pneumonia.  The 
mechanism  in  these  instances  is  the  same  as  in  pneumonia. 


PLEURISY,    ACUTE    AND    CflRONIC.  153 

pulmonary  resonance  be  found  then  to  extend  more  or 
less  below  this  line,  this  fact  is  demonstrative  proof  of 
the  presence  of  liquid.  Proof  in  this  way  is  obtained  in 
a  large  majority  of  cases,  the  exceptional  cases  being 
those  in  which  the  pleural  surfaces  are  united,  either  by 
agglutination  or  permanent  adhesions,  above  the  level  of 
the  liquid.^  The  resonance  on  percussion  over  the  lung 
above  the  level  of  the  liquid  is  generally  vesiculo-tym- 
panitic — the  intensity  increased,  the  pitch  raised,  the 
vesicular  and  the  tympanitic  quality  combined.  Some- 
times there  is  so  little  vesicular  quality  in  this  vesiculo- 
tympanitic resonance,  that  it  may  seem  to  be  purely 
tympanitic,  and  is  suggestive  of  pneumothorax.  Asso- 
ciated signs  will  always  prevent  this  error  of  observa- 
tion. As  a  rule,  vocal  resonance  and  fremitus  are  either 
notably  lessened  or  suppressed  over  the  portion  of  the 
chest  situated  below  the  level  of  the  liquid.  There  are 
occasional  exceptions  to  this  rule.  The  respiratory  sound 
below  the  level  of  the  liquid  is  suppressed.  If  any  be 
heard,  it  is  transmitted  either  from  the  lung  above  the 
liquid,  or  laterally,  from  the  lung  on  the  other  side  of 
the  chest.  Above  the  liquid  tlie  respiratory  sound,  as  a 
rule,  is  weakened.  If  the  amount  of  liquid  be  sufficient 
to  produce  much  condensation  of  lung,  the  respiratory 
sound  is  broncho-vesicular.  Sometimes,  owinu:  to  the 
pleural  surfaces  above  being  adherent,  a  strip  of  lung  at 

'  The  statement  with  regard  to  a  horizontal  line  denoting  the  level 
of  the  liquid  does  not  a})ply  to  the  posterior  aspect  of  the  chest.  Ob- 
servations show  that  posteriorly  the  lung  extends  more  or  less  down- 
ward near  the  spinal  column,  and  that  the  level  of  the  liquid  forms 
a  curve  which  may  be  represented  by  the  letter  S.  Vide  article  by 
Professor  G.  M.  Garland,  in  the  New  York  MedicalJournal,  number 
for  November,  1879.  Also,  treatise  on  "Pneu mono- Dynamics,"  by- 
Professor  G.,  1878. 


154  PHYSICAL    DIAGNOSIS. 

the  level  of  the  liquid  is  sufficiently  condensed  by  com- 
pression to  give  a  bronchial  respiration.  Under  these 
circumstances,  there  will  be  either  bronchophony  or  the 
modification  of  that  sign  known  as  segophony.  If  the 
lung  be  not  sufficiently  compressed  for  the  production  of 
these  signs  of  solidification,  the  vocal  resonance  is  sim- 
ply more  or  less  increased.  The  fremitus  is  usually  in- 
creased above  the  liquid.  Over  the  unaffected  side  the 
respiratory  murmur  is  increased  in  intensity. 

The  foregoing  signs  are  present  when  the  pleural 
cavity  is  partially  filled  ;  a  quarter,  a  half,  or  two-thirds 
of  the  thoracic  space  being  occupied  by  liquid.  The 
signs  present  when  the  cavity  is  completely  filled,  will 
be  presently  stated  in  connection  with  chronic  pleurisy. 

The  signs  which  have  been  stated  show  not  only  the 
presence  of  liquid,  but  its  quantity.  By  means  of  these 
signs  are  readily  ascertained  the  progressive  increase  or 
decrease  in  the  quantity  of  liquid,  and  its  disappearance. 
After  the  liquid  has  disappeared,  often  notable  dulness 
on  percussion  remains  for  some  time,  showing  the 
presence  of  lymph  not  yet  absorbed.  During  the 
decrease  of  the  liquid,  and  after  its  disappearance,  a 
friction-murmur  is  often  perceived.  This  murmur  is 
now  apt  to  be  rough — a  rasping,  grating,  or  creaking 
sound.  It  may  be  loud  enough  to  be  heard  by  the 
patient,  and  by  others  at  a  distance  from  the  chest.  It 
continues  sometimes  for  a  considerable  period. 

The  physical  diagnosis  in  cases  of  chronic  pleurisy, 
when  the  liquid  occupies  a  portion  only  of  the  thoracic 
space,  rests,  of  course,  on  precisely  the  same  signs  as  in 
cases  of  acute  pleurisy.  If,  however,  the  chest  on  the 
affected  side  be  filled  and  dilated,  certain  of  the  signs 
which   have  been  stated   are  wanting,  and  others  are 


PLEURISY,    ACUTE    AND    CHRONIC.  155 

added.  The  aifected  side  is  everywhere  flat  on  percus- 
sion. Flatness  on  percussion  over  the  whole  of  one  side, 
the  affection  being  chronic,  denotes,  as  a  rule,  with  rare 
exceptions,  either  chronic  simple  pleurisy  or  empyema. 
Respiratory  sound  is  wantin<^  except  at  the  summit  over 
or  near  the  compressed  lun<^,  where  it  is  bronchial. 
Some  cases  offer  an  important  exception  to  this  rule, 
namely,  the  bronchial  respiration  is  diffused  over  the 
greater  part,  or  even  the  whole,  of  the  affected  side. 
The  student  should  bear  in  mind  this  fact;  otherwise 
the  diffusion  of  the  bronchial  respiration  may  lead  to  the 
suspicion  that  the  flatness  on  percussion  denotes  solidifi- 
cation of  lung,  and  not  the  presence  of  liquid.  Other 
signs,  however,  should  always  correct  this  error.  A'^ocal 
resonance  and  fremitus  are,  with  some  exceptions,  either 
suppressed  or  notably  diminished  over  the  whole  of  the 
af!ected  side.  Generally,  even  when  the  chest  is  not 
dilated,  the  intercostal  depressions  are  lessened  or 
abolished.  If  the  walls  of  the  chest  be  thinly  covered 
with  integument,  the  two  sides  present  a  marked  contrast 
in  this  respect.  This  is  seen  especially  at  the  middle 
and  lower  regions  of  the  chest  anteriorly  and  laterally. 
It  is  especially  marked  at  the  end  of  the  inspiratory  act. 
If  the  affected  side  be  dilated,  this  is  apparent  on  inspec- 
tion, and  may  be  determined  accjurately  by  semicircular 
or  diametric  mensuration,  callipers  being  required  for 
the  latter.  The  respiratory  movements  on  the  affected 
side  are  diminished  or  annulled,  and  they  are  increased 
on  the  healthy  side,  the  two  sides  affording  a  marked 
contrast  in  this  regard.  If  the  pleurisy  be  on  the  left 
side,  the  impulses  of  the  heart  are  not  infrequently  felt 
on  the  right  of  the  sternum.  If  the  impulses  cannot  be 
felt,  auscultation  shows  the  maximum  of  the  intensity  of 


156  PHYSICAL    DIAGNOSIS. 

the  heart-sounds  to  be  more  or  less  removed  to  the  right. 
If  the  pleurisy  be  on  the  right  side,  the  impulses  or 
sounds  of  the  heart  denote  more  or  less  displacement 
laterally  to  the  left.  The  intensity  of  the  respiratory 
murmur  on  the  unaffected  side  is  notably  increased. 

In  cases  of  empyema  the  same  signs  are  present  as  in 
chronic  pleurisy.  Tlie  character  of  the  liquid  does  not 
alter  appreciably  any  of  the  signs  which  have  been 
stated.  Dilatation  of  the  affected  side  of  the  chest  is 
more  apt  to  occur,  and  to  be  more  marked  than  in  simple 
pleurisy.  The  differential  diagnosis  between  these  two 
varieties  of  pleurisy  is  to  be  made  with  positiveness  by 
the  introduction  of  the  needle  of  a  hypodermic  syringe 
having  good  suction  force,  previously  cleaned  and  car- 
bolized,  and  obtaining  enough  of  the  liquid  to  ascertain 
its  character. 

When  the  left  pleural  cavity  is  filled  with  j)us,  the 
movements  of  the  heart  sometimes  give  to  the  affected 
side  of  the  chest  an  impulse  ])erceived  by  the  eye  and 
touch  ;  hence,  the  term  pulsating  empyema.  After  a 
spontaneous  perforation  of  the  chest,  followed  by  a  cir- 
cumscribed purulent  collection  beneath  the  integument, 
communicating  with  the  pus  within  the  pleural  cavity, 
the  tuinor  thus  formed  sometimes  has  a  strong  pulsation 
which  is  synchronous  with  the  ventricular  systole,  and 
may  give  rise  to  the  suspicion  of  aneurism. 

In  cases  of  hydrothorax  the  signs  denote  partial  filling 
of  the  chest  on  both  sides.  The  affection  is  bilateral. 
Generally  the  quantity  of  liquid  in  the  two  sides  is  not 
equal,  and  there  is  often  a  notable  disparity  in  this 
respect.  Friction-sounds  are  never  present.  Variation 
of  the  level  of  the  liquid  with  change  of  the  position  of 
the  patient  from  the  vertical  to  the  horizontal,  is  nearly 


PNEUMOTHORAX.  157 

always  determinable.  Hydrothorax,  meaning  by  this 
term  a  purely  dropsical  affection,  is  to  be  differentiated 
from  double  pleurisy  with  effusion.  The  history  and 
symptoms,  taken  in  connection  with  the  signs,  suffice  for 
this  discrimination. 

Pneumothorax — Pneumo-hydrotliorax — Pneumo- 
pyothorax. 

In  the  extremely  rare  cases  of  pneumothorax,  that  is, 
as  distinguished  from  pneumo-hydrothorax  and  pneumo- 
pyothorax,  the  physical  conditions  are :  the  presence  of 
air  partially  or  completely  occupying  the  thoracic  space, 
and  condensation  of  lung  in  proportion  to  the  space  oc- 
cupied by  air. 

The  diagnostic  signs  are,  a  purely  tympanitic  resonance 
over  a  portion  or  the  whole  of  the  affected  side  of  the 
chest:  suppression  of  the  vesicular  murmur  over  a  space 
corresponding  to  that  in  which  tympanitic  resonance  is 
obtained,  with  notable  diminution  or  suppression  of  vocal 
resonance  and  fremitus.  Over  the  compressed  lung,  if 
the  condensation  amount  to  complete  or  considerable  so- 
lidification, there  will  be  bronchial  respiration  and  bron- 
chophony; if  the  solidification  be  neither  complete  nor 
considerable,  there  W'ill  be  broncho-vesicular  respiration 
with  increased  vocal  resonance  and  fremitus.  The  accu- 
mulation of  air  may  be  sufficient  to  dilate  the  affected 
side,  and  to  restrain  or  annul  the  respiratory  movements 
on  this  side.  The  appearances  on  inspection  are  then 
precisely  the  same  as  in  the  cases  of  chronic  pleurisy  and 
empyema  in  which  the  affected  side  is  dilated  from  the 
presence  of  liquid.  Pneumothorax  is,  however,  at  once 
differentiated  by  the  tympanitic  resonance  on  percussion. 
If  one  side  of  the  chest  be  more  or  less  dilated,  and  the 

,14 


158  PHYSICAL    DIAGNOSIS. 

resonance  over  the  side  be  purely  tympanitic,  the  thora- 
cic space  must  be  filled,  not  with  liquid  but  with  air. 
The  intensity  of  the  respiratory  murmur  on  the  healthy 
side  is  increased. 

In  the  great  majority  of  cases  in  which  the  pleural 
cavity  contains  air,  there  is  also  present  more  or  less 
liquid,  which  may  be  serous  or  purulent.  The  affection 
is  then  known  as  pneumo-hydrothorax  if  the  liquid  be 
serous,  and  pneumo-pyothorax  if  it  be  purulent.  The 
physical  conditions  are  the  same  as  in  pneumothorax,  with 
the  addition  of  the  presence  of  liquid.  The  relative 
proportions  of  liquid  and  air  in  different  cases  are  variable, 
and,  also,  in  the  same  case  at  different  periods. 

The  physical  diagnosis  of  pneumo-hydrothorax  and  of 
pneumo-pyothorax,  as  distinguished  from  pneumothorax, 
embraces  the  signs  of  liquid,  in  addition  to  those  of  air, 
within  the  pleural  cavity.  If  the  quantity  of  liquid  be 
large  or  considerable,  percussion  at  the  base  of  the  chest 
gives  flatness  extending  upward  more  or  less,  and  tym- 
panitic resonance  above,  the  patient  either  sitting  or 
standing.  A  change  from  the  vertical  to  the  horizontal 
position  invariably  causes  variation  of  the  upper  limit  of 
the  flatness,  inasmuch  as  the  liquid  and  air  change  their 
relative  situations  without  an  exception.  The  quantity  of 
liquid  is  determined  approximatively  by  ascertaining  the 
space  over  which  the  flatness  on  percussion  extends. 
The  line  which  divides  the  flatness  and  the  tympanitic 
resonance  does  not  accurately  denote  the  level  of  the 
liquid,  because  tympanitic  resonance  is  transmitted  a  cer- 
tain distance  below  this  level,  hence  it  is  always  to  be 
assumed  that  the  level  of  the  liquid  is  somewhat  higher 
than  the  upper  boundary  of  the  flatness. 

In  either  pneumothorax,  pneumo-hydrothorax,  or 
pneumo-pyothorax  a  group  of  auscultatory  signs  is  often 


ACUTE  LOBAR  PNEUMONIA.         159 

found  which  are  highly  diagnostic,  indeed  almost  pathog- 
nomonic. These  signs  are  amphoric  respiration,  ampho- 
ric voice  or  echo,  and  metallic  tinkling.  The  amphoric 
and  the  tinkling  sounds  may  be  present,  either  without 
the  other,  but  they  are  not  infrequently  associated. 
Neither  are  present  in  every  case,  and  they  are  not  pres- 
ent in  the  same  case  at  all  times;  their  absence,  there- 
fore, by  no  means  excludes  the  affections,  and  they  are 
not  essential  to  the  diagnosis.  When  present  they  de- 
note either  air  or  air  and  liquid  in  the  pleural  cavity  with 
perforation  of  lung  or  a  large  phthisical  cavity.  Their 
occurrence  in  the  latter  is  comparatively  rare,  and  when- 
ever they  are  associated  with  other  signs  already  stated, 
their  diagnostic  import  is  demonstrative. 

Pneumo-hydrothorax  or  pneumo-pyothorax  may  al- 
most invariably  be  diagnosticated  instantly  by  the  pres- 
ence of  a  succussion  sound.  Whenever  distinct  splash- 
ing is  produced  by  succussion  and  referable  to  the  chest, 
that  is,  not  produced  within  the  stomach,  it  is  demon- 
strative of  the  presence  of  air  and  liquid  within  the 
pleural  cavity. 

Acute  Lohar  Pneumonia. 
In  the  first  stasfe  of  this  disease  there  is  an  abnormal 
accumulation  of  blood  within  the  vessels  of  the  affected 
lobe  (active  congestion  or  hyper?emia),  with  some  exu- 
dation within  the  air-vesicles  and  bronchioles.  Gener- 
ally there  is  some  exuded  lymph  upon  the  pleural  surface, 
this  being  due  to  circumscribed  dry  pleurisy.  In  most 
cases  there  is  also  circumscribed  bronchitis,  which  is  lim- 
ited to  the  tubes  within  the  affected  lobe.  In  the  second 
stage  there  is  solidification  due  to  the  increase  of  exu- 
dation within  the  air-vesicles.  The  solidification,  at  first 
limited,  extends  either  rapidly  or  slowly,  as  a  rule,  over 


160  PHYSICAL    DIAGNOSIS. 

the  whole  lobe.  Exceptionally  more  or  less  liquid  effu- 
sion into  the  pleural  cavity  takes  place  (pleuro-pneumo- 
nia),  the  pleurisy  then  extending  beyond  the  limits  of 
the  affected  lobe.  In  this  stage  the  pneumonia  may  in- 
volve either  another  lobe  of  the  lung  primarily  affected, 
or  a  lobe  of  the  opposite  lung,  and  sometimes  the  dis- 
ease, by  successive  invasions,  extends  over  the  whole  of 
one  lung,  together  with  a  lobe  of  the  opposite;  lung.  The 
pneumonia,  in  these  secondary  invasions,  is  usually  ac- 
companied by  pleurisy  and  bronchitis.  In  the  stage  of 
resolution  the  solidification  of  the  affected  lobe  or  lobes 
decreases,  sometimes  rapidly  and  sometimes  slowly,  until 
the  normal  condition  is  restored.  If  resolution  do  not 
take  place,  and  the  disease  pass  into  the  stage  of  puru- 
lent infiltration,  the  air-vesicles  and  bronchial  tubes  con- 
tain a  puruloid  liquid  in  greater  or  less  quantity.  Ex- 
ceptionally pus  is  collected  in  a  cavity,  or  in  cavities, 
constituting  pulmonary  abscess. 

The  physical  diagnosis  of  acute  lobar  pneumonia  in 
the  first  stage  must  be  based  on  the  presence  of  the  crep- 
itant rale,  with  moderate  or  slight  dulness  on  percussion 
over  the  affected  lobe.  There  is  sometimes  in  this  stage 
a  pleuritic  rubbing  sound  over  the  affected  lobe.  The 
crepitant  rale  is  not  always  present,  and  hence  the  affec- 
tion cannot  be  excluded  by  the  absence  of  this  sign. 
When  present,  taken  in  connection  with  the  symptoms, 
this  sign  is  pathognomonic  of  the  disease.  It  is  impor- 
tant not  to  mistake  for  this  sign  fine  bubbling  or  the 
subcrepitant  rale.  When  the  crepitant  rale  is  wanting,  a 
positive  physical  diagnosis  must  be  deferred  until  more 
or  less  of  the  affected  lobe  becomes  solidified,  that  is, 
when  the  disease  passes  into  tlie  second  stage. 

The  diagnosis  in  the  second  stage  is  to  be  based  on 


ACUTE    LOBAR    PNEUMONIA.  161 

tl)e  signs  of  solidification  furnished  by  auscultation  and 
percussion.  The  auscultatory  signs  are  the  broncho- 
vesicular,  followed  by  the  bronchial  respiration;  in- 
creased vocal  resonance,  followed  by  bronchophony,  and 
increased  bronchial  whisper,  followed  by  whispering  bron- 
chophony. The  signs  of  solidification  are  manifest  at 
first  within  a  circumscribed  space,  situated  over  either 
the  upper,  the  lower,  or  the  middle  portion  of  the  affected 
lobe,  and  either  rapidly  or  slowly  the  signs  extend  in 
most  cases  over  the  entire  lobe.  The  crepitant  rale,  if 
it  have  been  present  in  the  first,  generally  disappears  in 
the  second  stage.  Sometimes,  however,  it  is  not  entirely 
lost  in  this  stage.  The  broncho-vesicular  respiration, 
increased  vocal  resonance,  and  increased  bronchial  whis- 
per are  present  when  the  solidification  is  slight  or  moder- 
ate ;  the  bronchial  respiration,  bronchophony,  and  bron- 
chophonic  whisper  take  their  place  when  the  solidification 
becomes  considerable  or  complete.  The  latter  signs,  as 
a  rule,  speedily  follow,  inasmuch  as  the  solidification  in 
most  cases  quickly  becomes  complete  or  considerable. 
The  foregoing  three  signs,  denoting  considerable  or  com- 
plete solidification,  are  usually  present.  Bronchial  res- 
piration, however,  is  sometimes  present  without  broncho- 
phony, and  vice  versa.  Either,  present  alone,  suffices  to 
show  the  existence  and  the  extent  of  the  solidification. 
-Moist  bronchial  or  bubbling  rales  are  sometimes,  but 
rarely,  heard  over  the  affected  lobe. 

There  is  notable  dulness  on  percussion  in  the  second 
stage.  The  dulness  may  approximate,  and  even  amount 
to  flatness.  If  a  single  lobe  be  affected,  the  dulness  or 
flatness  extends  over  a  space  corresponding  to  that  occu- 
pied by  the  lobe  or  the  portion  of  it  which  is  solidified. 
In  the  antero-lateral  aspects  of  the  chest,  the  dividing 


1G2  PHYSICAL    DIAGNOSIS. 

line  between  the  solidified  and  the  healthy  lobe  is  readily 
ascertained  by  percussion,  and  this  line  is  coincident 
with  the  interlobar  fissure.  It  sometimes  happens  that 
the  upper  and  the  lower  lobe  of  the  right  lung  are 
affected,  the  middle  lobe  not  becoming  involved.  The 
space  corresponding  to  the  middle  lobe  may  then  form 
an  island  of  resonance  surrounded  by  notable  dulness 
on  percussion. 

Whenever  one  lobe  of  a  lung  is  affected,  the  resonance 
over  the  unaffected  part  of  the  same  lung  is  abnormally 
increased,  the  pitch  is  raised,  and  the  quality  is  vesiculo- 
tympanitic; vesiculo-tympanitic  resonance,  in  other  words, 
13  produced.  This  renders  more  marked  the  contrast  be- 
tween dulness  over  the  solidified,  and  resonance  over  the 
healthy,  lobe. 

Over  a  portion  of  an  upper  lobe  in  the  second  stage, 
instead  of  notable  dulness  or  flatness,  there  may  be 
marked  tympanitic  resonance.  Tliis  resonance  proceeds 
from  air  within  the  trachea  and  the  bronchi  exterior  to 
the  lungs,  the  lung  substance  being  completely  solidified; 
it  is  chiefly  or  especially  marked  over  the  site  of  these 
air-tubes.  In  some  cases  the  tympanitic  resonance  has 
either  the  cracked-metal  or  the  amphoric  intonation. 
These  signs,  per  se,  might  suggest  either  pneumothorax 
or  phthisical  cavities ;  the  associated  respiratory  and  vocal 
signs,  however,  show  only  solidification  of  lung.  In  cases 
of  pneumonia  affecting  the  left  lung,  a  tympanitic  reso- 
nance is  not  infrequently  propagated  from  the  stomach 
more  or  less  upward  over  the  affected  side  of  the  chest. 
This  may  be  readily  traced  to  the  stomach.  On  tlie 
right  side,  a  tympanitic  resonance  is  sometimes  propa- 
gated a  certain  distance  upward  from  the  transverse 
colon. 


ACUTE  LOBAR  PNEUMONIA.         1G3 

The  commencement  of  the  stage  of  resolution  is  de- 
noted by  a  broucho- vesicular  respiration.  The  first 
change  observed  is  the  presence  of  a  little  vesicular 
quality  in  the  inspiratory  sound.  When  this  is  observed, 
the  respiration  is  no  longer  bronchial,  but  has  become 
broncho-vesicular,  althou_o;h  the  pitch  is  still  high,  and 
the  expiration  is  prolonged,  high,  tabular.  This  slight 
change  shows  that  air  begins  to  enter  the  pulmonary  vesi- 
cles. As  resolution  goes  on,  more  and  more  of  the  ve- 
sicular takes  the  place  of  the  tubular  quality  in  the  in- 
spiratory sound,  and  the  pitch  is  lowered  in  proportion; 
the  expiratory  sound  becomes  proportionally  less  and  less 
prolonged,  its  pitch  lowered,  its  quality  less  tubular, 
until,  at  length,  the  normal  characters  of  the  respiratory 
murmur  are  regained.     Kesolution  is  then  complete. 

While  the  broncho-vesicular  respiration  is  undergoing 
the  modifications  just  stated,  the  vocal  sounds  have  cor- 
responding changes.  Bronchophony  persists  for  some 
time  after  the  respiration  has  become  broncho-vesicular, 
and  then  disappears,  increased  vocal  resonance  generally 
taking  its  place  and  persisting  until  resolution  is  com- 
pleted. The  bronchial  whisper  loses  its  bronchophouic 
characters,  and  is  simply  increased  until  its  normal  char- 
acters are  regained.  While  the  solidification  is  com- 
plete, the  vocal  fremitus  may,  or  may  not,  be  increased. 
It  is  sometimes  diminished.  When,  however,  resolution 
has  so  far  progressed  that  bronchophony  is  lost,  the  frem- 
itus is  usually  greater  than  in  health,  and  so  continues, 
but  progressively  lessening  until  the  solidification  entirely 
disappears. 

During  the  progress  of  resolution,  the  dulness  on  per- 
cussion diminishes  in  proportion  as  air  enters  the  air- 
vesicles.     If  tympanitic  resonance    have  been  present 


16i  PHYSICAL    DIAGNOSIS. 

over  the  upper  lobe,  this  gives  place  to  a  vesicular  reso- 
nance. Some  dulness.  however,  remains  after  the  com- 
pletion of  resolution,  and  persists  until  the  exuded  lymph 
on  the  pleural  surface  is  absorbed.  The  amount  of  dul- 
ness remaining  when  the  respiratory  and  vocal  signs 
denote  resolution,  is  proportionate  to  the  quantity  of  exu- 
dation incident  to  the  associated  pleurisy. 

In  this  stage  the  crepitant  rale  not  infrequently  returns, 
if  it  have  entirely  disappeared  during  the  second  stage, 
and  if  it  have  persisted,  it  is  more  marked  and  diffused. 
It  is  now  known  as  the  returning  crepitant  rale.  More 
frequently  the  rale  in  this  stage  is  a  fine  bubbling  or 
the  subcrepitant.  Both  rales  are  not  infrequently  asso- 
ciated, and,  from  the  distinctive  characters  of  each,  they 
are  readily  distinguished.  Moist  rales  more  or  less  fine 
or  coarse  are  not  infrequent. 

If  the  affection  pass  into  the  stage  of  purulent  infiltra- 
tion, the  respiratory  sounds  are  feeble  or  suppressed, 
having,  if  present,  more  or  less  of  the  bronchial  charac- 
ters. Bubbling  bronchial  rales,  coarse  and  fine,  are 
abundant.  Weak  bronchophony  may  persist,  or  the 
vocal  resonance  may  be  diminished.  Fremitus  may,  or 
may  not,  be  increased.  Notable  dulness  or  flatness  on 
percussion  remains. 

If  the  pneumonia  result  in  pulmonic  abscess,  there 
will  be  notable  dulness  or  flatness  on  percussion  within  a 
circumscribed  space,  together  with  absence  of  respiratory 
murmur,  and  diminished  or  suppressed  vocal  resonance. 
These  signs  warrant  a  probable  diagnosis  which  is  cor- 
roborated by  the  sudden  expectoration  of  pus  in  a  con- 
siderable quantity.  The  signs  just  stated  may  then  be 
followed  by  those  denoting  a  cavity,  namely,  cavernous 
respiration  and  whisper,  with  intense  vocal  resonance. 


EMBOLIC    PNEUMONIA.  165 

Circumscribed  Pneumonia— Embolic  Pneumonia — Haemor- 
rhagic  Infarctus  or  Pulmonary  Apoplexy. 

The  form  of  pneumonia  known  as  lobular  pneumonia, 
occurring  chiefly  in  children,  has  been  considered  (vide 
Bronchitis  seated  in  small-sized  tubes).  Whenever  cir- 
cumscribed, as  a  rule,  pneumonia  is  secondary  to  some 
other  pulmonary  affection.  Circumscribed  pneumonia, 
giving  rise  to  an  intra-vesicular  exudation  which  may 
disappear  readily  by  resolution  or  absorption,  is  not  very 
infrequent  in  cases  of  phthisis.  The  signs  are  those  which 
represent  solidification  of  lung  within  an  area  more  or 
less  circumscribed ;  but  the  differentiation  from  the 
solidification  proper  to  phthisis  can  only  be  made  with 
positiveness  after  the  signs  have  shown  that  the  solidifi- 
cation has  notably  diminished  or  disappeared. 

In  embolic  pneumonia  there  may  be  dulness  on  per- 
cussion, with  feeble  bronchial  or  broncho- vesicular  res- 
piration, or  suppression  of  respiratory  sound,  weak 
bronchophony  or  increase  of  vocal  resonance,  within  a 
circumscribed  space,  or  within  spaces,  generally  on  the 
posterior  aspect  of  the  chest,  and  oftenest  on  the  right  side. 
These  signs,  taken  in  connection  with  the  symptoms  and 
pathological  conditions  which  are  consistent  with  the 
supposition  of  emboli  received  into  the  right  side  of  the 
heart,  namely,  when  the  pulmonary  symptoms  follow 
puerperal  disease,  ulcers,  wounds,  injuries,  or  venous 
thrombosis,  render  the  diagnosis  quite  positive.  If,  how- 
ever, the  pulmonary  affection  consist  of  small  dissemi- 
nated nodules,  the  foregoing  signs  will  not  be  present. 
The  diagnosis  then  must  be  based  on  the  history  and 
symptoms,  taken  in  connection  with  the  exclusion  of  other 
pulmonary  affections  by  the  absence  of  signs  which  should 
be  present  if  they  existed.     Bubbling  rales  at  different 


166  PHYSICAL    DIAGNOSIS. 

situations  may  indicate  the  probable  sites  of  tiie  nodules. 
There  may  be  pleuritic  friction-sounds.  The  signs  may 
show,  as  a  complication,  pleurisy  with  effusion. 

Extravasation  of  blood  (pneumorrhagia),  if  it  be  in 
small  spaces,  gives  rise  to  no  definite  physical  signs.  If, 
however,  extravasation  extend  over  a  considerable  space, 
there  will  be  dulness  on  percussion,  with  feeble  or  sup- 
pressed respiratory  sound  within  an  area  corresponding 
to  the  extent  of  the  extravasation.  Within,  and  near 
this  area,  there  will  be  likely  to  be  moist  bronchial  rales 
more  or  less  fine  or  coarse.  The  signs  of  solidification 
will  not  be  present  if  the  extravasation  be  unaccompanied 
by  pneumonia. 

Pulmonary  Gangrene. 

In  diffused  pulmonary  gangrene  the  physical  signs  are 
those  of  solidification,  extending  over  the  greater  part  or 
the  whole  of  a  lobe.  The  diagnosis,  however,  can  only 
be  made  when,  in  connection  with  these  signs,  there  are 
present  the  characteristic  fetor  of  the  breath  and  expec- 
toration. 

In  circumscribed  gangrene  there  is  dulness  or  flatness 
on  percussion  within  an  area  corresponding  to  the  extent 
of  the  affection,  with  either  suppression  of  respiratory 
sound,  or  bronchial  respiration,  and  the  vocal  signs  of 
solidification.  Within  and  near  this  space  moist  bron- 
chial rales  are  likelv  to  be  heard.  The  situation  is  usu- 
ally  on  the  posterior  aspect  of  the  chest.  These  signs 
do  not  suffice  for  a  positive  diagnosis  without  the  char- 
acteristic breath  and  expectoration.  Cavernous  signs 
may  appear  after  the  gangrenous  portion  of  lung  has 
sloughed  away  and  been  expectorated. 


PULMONARY    (EDEM.A.  1G7 

Pulmonary  (Edema. 

The  physical  condition  expressed  by  the  term  ])nlmo- 
nary  oedema  is  the  presence  of  effused  serum  witliin  the 
air-vesicles.  With  this  condition  is  associated  more  or 
less  pultnonary  congestion. 

In  cases  of  pulmonary  oedema  developed  ra])idly  and 
largely  in  connection  with  renal  disease,  with  obstruction 
at  the  mitral  orifice  of  the  heart,  or  with  both  these  af- 
fections combined,  giving  rise  to  great  dyspnoea,  and 
liable  to  end  speedily  in  death,  the  following  are  the  diag- 
nostic signs:  Dulness  on  percussion  on  both  sides  of  the 
chest,  especially  over  the  lower  lobes,  line  bubbling  or  the 
subcrepitant  rale  diffused  over  the  chest  on  both  sides, 
together  with  coarser  bubbling  sounds,  and  the  murmur 
of  respiration  notably  weak  or  su})pressed  over  the  lower 
lobes.  Inasmuch  as  thelungsare  notsolidificd  the  rales 
are  low  in  pitch.  The  vocal  signs  of  solidification  are, 
of  course,  wanting.  Occasionally  the  crepitant  rale  is 
mingled  with  the  fine  bubbling  sounds. 

This  form  of  the  affection  is  to  be  differentiated  from 
hydrothorax  with  large  effusion,  and  from  so-called  ca- 
pillary bronchitis.  Hydrothorax  is  always  associated 
with  more  or  less  anasarca,  or  general  dropsy,  whereas, 
pulmonary  cedema,  even  when  dependent  on  renal  dis- 
ease, may  occur  without  dropsical  effusion  elsewhere. 
Moreover,  the  presence  of  liquid  within  the  pleural 
cavities,  and  its  amount,  may  always  be  determined  de- 
monstratively in  cases  of  hydrothorax  (vide  Pleurisy 
with  effusion  and  Hydrothorax).  Capillary  bronchitis 
occurs  chiefly  in  children.  The  subcrej)itant  rale  on  both 
sides  of  the  chest  is  the  diagnostic  sign  of  this  affection, 
but  it  is  not  accompanied  by  dulness  on  percussion,  ex- 
cept in  so  far  as   the  bronchitis  may  be  associated  with 


168  PHYSICAL    DIAGNOSIS. 

lobular  pneumonia  or  collapse  of  pulmonary  lobules. 
The  rapid  development  of  the  oedema  and  its  pathologi- 
cal connections,  are  diagnostic  points  to  be  taken  into  ac- 
count. 

Pneumonia  is  excluded  by  the  fact  that  the  affection  is 
at  the  beginning  bilateral,  and  by  the  absence  of  the  signs 
of  solidification  of  lung. 

Pulmonary  oedema,  less  in  degree  and  diffusion,  has,  of 
course,  the  same  signs,  not  as  marked  and  not  as  exten- 
sive, namely,  dulness  on  percussion  and  fine  bubbling 
sounds  or  the  subcrepitant  rale.  In  this  form  the  affec- 
tion is  bilateral,  and  seated  especially  in  the  posterior 
and  inferior  portions  of  the  lungs.  Moreover,  this  form 
has  the  same  pathological  connections,  namely  with  dis- 
ease of  the  kidneys,  and  mitral  lesions  of  the  heart.  The 
low  pit.^h  of  the  bronchial  rales,  and  the  absence  of  the 
respiratory  and  vocal  signs  of  solidification,  together  with 
the  fact  of  the  affection  being  bilateral,  and  the  coex- 
istence of  disease  of  the  heart  or  kidneys,  constitute  the 
basis  of  a  positive  diagnosis. 

Hypostatic  congestion  of  the  lungs  may  occasion  a 
certain  amount  of  pulmonary  oedema.  The  physical 
diagnosis  is  to  be  based  on  bilateral  dulness  on  the  pos- 
terior aspect  of  the  chest,  with  low-pitched,  fine  bubbling 
sounds,  or  the  subcrepitant  rale  on  both  sides,  these  signs 
occurring  under  circumstances  which  lead  to  the  suppo- 
sition of  this  form  of  congestion. 

Carcinoma  of  Lung — Tumors  within  the  Chest. 

Carcinomatous  growths  in  the  lungs  are  usually  in 
the  form  of  nodules  varying  in  size  from  that  of  a  pea  to 
a  hen's  egg,  disseminated  throughout  one  lung  or  both 
lungs,  in  greater  or  less  numbers.     These  disseminated 


CARCINOMA    OF    LUNG.  169 

nodules,  if  of  small  size,  have  no  well-marked,  definite 
diagnostic  signs.  If  limited  to  a  lung,  or  if  greater  in 
number  in  one  lung,  they  may  occasion  an  appreciable 
dulness  on  percussion.  They  may  also  occasion  feeble- 
ness of  the  respiratory  murmur,  and,  owing  to  coexist- 
ing circumscribed  bronchitis,  moist  bronchial  rales  may 
be  heard  at  different  points.  These  signs  warrant  a  di- 
agnosis when,  as  is  usually  the  case,  cancer  is  known  to 
have  existed  elsewhere.  With  reference  to  diagnosis,  it 
is  to  be  borne  in  mind  that,  when  cancer  of  the  lung  is 
secondary,  both  lungs  are  affected,  and,  when  it  is 
primary,  the  affection  is  generally  unilateral. 

If  there  be  nodules  of  considerable  size,  there  will  be 
well-marked  dulness  on  percussion  in  different  situations, 
and  the  signs  of  solidification  may  be  present,  namely, 
either  bronchial  or  broncho-vesicular  respiration,  either 
increased  vocal  resonance  or  bronchophony,  and  in- 
creased vocal  fremitus. 

In*  some  cases  of  unilateral  carcinoma,  the  greater 
part,  or  the  whole,  of  a  lung  may  be  infiltrated  with  the 
morbid  growth,  increasing  its  volume  and  giving  rise  to 
enlargement  of  the  affected  side,  diminished  respiratory 
movements  or  immobility,  flatness  on  percussion,  with 
diminished  or  suppressed  respiratory  murmur,  vocal 
resonance,  and  fremitus.  If,  as  is  usual,  there  be  also 
more  or  less  pleuritic  effusion,  the  intercostal  spaces  may 
be  pushed  out  to  a  level  with  the  ribs.  Here  are  the 
signs  which  denote  chronic  pleurisy  with  large  effusion, 
and  the  differential  diagnosis  cannot  be  made  with  posi- 
tiveness  until  the  Huid  within  the  chest  be  withdrawn, 
and  it  be  found  that,  irrespective  of  the  bulging  of  the 
intercostal  spaces,  the  physical  signs  remain.  Explora- 
tion with  a  small  trocar,  or  hollow  needle,  will  settle  the 


170  PHYSICAL    DIAGNOSIS. 

diagnosis  when  there  is  no  pleuritic  effusion,  and  this 
procedure  is  unobjectionable. 

In  other  cases  the  carcinomatous  growth  induces 
atrophy  of  the  lung,  diminishing  its  volume,  and  causing 
notable  contraction  of  the  affected  side.  The  appear- 
ances on  inspection  are  those  which  denote  contraction 
after  chronic  pleurisy,  and  they  may  be  present  also  in 
cases  of  cirrhosis  of  lung.  The  differential  diagnosis 
must  be  based  chiefly  on  diagnostic  points  relating  to  the 
history  and  symptoms. 

Tumors  within  the  chest,  generally  having  their  points 
of  departure  in  the  mediastinum,  displace  the  lung  in 
proportion  to  their  size.  They  may  cause  considerable 
displacement  of  the  heart,  and  ])roduce  more  or  less 
enlargement  of  the  chest  with  diminished  respiratory 
movements.  Enlargement  of  the  subcutaneous  veins, 
indicative  of  venous  obstruction,  is  often  to  be  observed. 
Over  the  site  of  the  tumor,  there  will  be  either  dulness 
or  flatness  on  percussion.  Generally  respiratory  sound 
is  wanting,  vocal  resonance  and  fremitus  being  either 
diminished  or  suppressed.  In  the  neighborhood  of  the 
primary  bronchi  and  over  lung  compressed  by  the  tumor, 
there  may  be  bronchial  respiration,  with  bronchophony 
and  increased  fremitus.  If  the  chest  be  enlarged,  its 
enlargement  is  not  likely  to  be  as  uniform  as  when  it  is 
dilated  with  liquid  ;  this  is  a  diagnostic  point.  The 
tumor,  or  the  tumors,  may  not  be  confined  to  one  side 
of  the  chest.  It  is  to  be  borne  in  mind  that  pleurisy 
with  effusion  may  exist  as  a  complication,  and  this  may 
serve  to  obscure  the  diagnosis. 

The  physical  diagnosis  involves  differentiation  from 
pericarditis  with  effusion  and  aneurisms.     These  affec- 


ACUTE    MILIARY    TUBERCULOSIS.  171 

lions  are  to  be  excluded  by  the  absence  of  their  diagnostic 
signs. 

Acute  Miliary  Tuberculosis. 

The  physical  condition  in  tliis  affection  is  the  presence 
of  a  larcre  number  of  the  small  bodies  known  as  tubercles 
or  miliary  granulations,  disseminated  throughout  both 
lungs.     Bronchitis  is  an  associated  affection. 

If  the  tubercles  be  about  equally  distributed  in  the 
two  lungs,  there  is  no  abnormal  disparity  of  the  reso- 
nance on  percussion  betw'een  the  two  sides  of  the  chest. 
A  comparison,  also,  of  the  two  sides  may  afford  no 
disparity  as  regards  the  respiratory  murmur,  vocal 
resonance,  and  fremitus.  Moist  rales,  due  to  the  asso- 
ciated bronchitis,  maybe  present  in  different  situations. 
A  pln'sical  diagnosis,  under  these  circumstances,  cannot 
be  made  with  positiveness.  Physical  exploration,  how- 
ever, is  important,  in  order  to  exclude  other  affections  ; 
and  the  negative  result,  taken  in  connection  with  the 
symptoms  —  hyperpyrexia,  rapid  pulse,  accelerated 
breathing,  etc  — renders  the  diagnosis  extremely  proba- 
ble. The  differential  diagnosis  involves  discrimination 
from  capillary  bronchitis,  and  an  essential  fever  with  a 
bronchial  complication.  The  affection  has  been  re- 
peatedly mistaken  for  typhoid  fever. 

The  tubercles  may  be  more  abundantly  distributed  in 
one  lung.  A  disparity  in  the  resonance  on  percussion 
may  then  be  apparent,  and,  perhaps,  an  abnormal 
increase  of  vocal  resonance  and  fremitus.  These  signs, 
taken  in  connection  with  the  symptoms,  establish  the 
physical  diagnosis. 


172  PHYSICAL    DIAGNOSIS. 

Phthisis. 

With  reference  to  physical  diagnosis,  cases  of  phthisis 
may  be  conveniently  distributed  into  three  groups,  as 
follows:  1st.  Cases  in  which  the  pulmonary  affection  is 
small,  or  cases  of  incipient  phthisis;  2d.  Cases  in  which 
the  affection  is  moderate  or  considerable  ;  and  3d.  Cases 
in  which  the  affection  has  progressed  to  the  formation  of 
cavities,  or  cases  of  advanced  phthisis. 

In  cases  of  incipient  phthisis,  the  essential  physical 
condition  is  the  presence  of  small  solidified  masses,  or 
nodules,  the  intervening  vesicular  structure  not  being 
affected.  These  nodules  vary  from  the  size  of  a  pea  to 
a  filbert.  In  the  vast  majority  of  cases  they  are  situated 
at  or  near  the  apex  of  either  the  right  or  the  left  lung. 
Generally,  circumscribed  capillary  bronchitis  coexists  in 
proximity  to  the  nodules.  An  intercurrent  circumscribed 
pneumonia  sometimes  occurs,  giving  rise  to  transient 
solidification  within  a  limited  area.  Dry  circumscribed 
pleurisy,  situated  over  the  affected  portion  of  lung,  gene- 
rally occurs  from  time  to  time. 

In  the  cases  of  a  moderate  or  a  considerable  pulmon- 
ary affection,  the  difference,  as  compared  with  the  pre- 
ceding group  of  cases,  consists  in  the  presence  of  nodules 
of  larger  size,  or  solidification  from  the  phthisical  deposit 
extending  over  a  space,  or  spaces,  sufficient  in  size  to 
give  rise  to  well-marked  physical  signs.  The  solidifica- 
tion in  these  cases  may  be  extended  by  the  development 
of  circumscribed  interstitial  pneumonia.  The  circum- 
scribed bronchitis  is  greater,  as  a  rule,  in  degree  and  ex- 
tent; attacks  of  dry  pleurisy  may  continue  to  occur,  and 
the  pleural  surface  becomes  adherent.  In  these  cases, 
generally,  the  affection,  existing  primarily  in  one  lung, 
now  exists  in  both  lungs.    The  volume  of  the  lung  first 


PHTHISIS.  173 

affected,  at  the  summit,  is  more  or  less  diminished.  En- 
largement of  the  bronchial  glands  is  usual,  and  these 
may  be  so  situated  as  to  press  upon  and  diminish  the 
calibre  of  one  of  the  primary  bronchi.  In  some  cases, 
portions  of  lung  in  the  neighborhood  of  solidified  masses 
or  nodules  are  emphysematous  (vicarious  emphysema). 

Cases  of  advanced  phthisis  are  characterized  by  the 
presence  of  a  cavity,  or,  commonly,  of  cavities,  varying 
in  number,  size,  rigidity  or  flaccidity  of  the  walls,  free- 
dom of  communication  with  bronchial  tubes,  and  their 
situation  relatively  to  the  superficies  of  the  lung.  In 
cases  of  progressive  phthisis,  in  addition  to  cavities,  there 
is  more  or  less  solidification  from  phthisical  exudation 
and  interstitial  pneumonia.  The  volume  of  the  lung  at 
the  summit  is  often  notably  diminished.  The  pleural 
surfaces  are  firmly  adherent.  If,  however,  the  disease 
have  been  retrogressive,  there  may  be  little  or  no  solidifi- 
cation of  lung,  the  cavity  or  cavities  forming  the  only 
lesion.  In  cases  of  advanced  phthisis,  with  very  rare 
exceptions,  both  lungs  are  affected,  and  cavities  often 
exist  on  both  sides. 

The  physical  diagnosis  in  cases  of  incipient  phthisis 
embraces  what  may  be  called  direct  and  accessory  signs. 
The  accessory  signs  are  those  which  represent  incidental 
aff'ections,  namely,  circumscribed  bronchitis,  pleurisy, 
and  pneumonia.  The  direct  signs  are  those  represent- 
ing the  essential  condition,  namely,  the  solidified  masses 
or  nodules. 

An  important  direct  sign  is  dulness  on  percussion. 
Slight  dulness  on  percussion  at  the  summit  of  the  chest, 
in  front  or  behind,  is  a  highly  important  sign,  taken  in 
connection  with  symptoms,  of  incipient  phthisis.  In  de- 
termining that  a  relative  dulness  is  abnormal,  the  student 

15 


174  PHYSICAL    DIAGNOSIS. 

must  bear  in  mind,  in  the  first  place,  the  normal  disparity 
between  the  two  sides.  The  right  side  at  the  summit  is 
relatively  somewhat  dull  on  percussion  in  healthy  persons. 
Due  allowance  is  to  be  made  for  this  normal  disparity. 
In  the  second  place,  it  is  to  be  borne  in  mind  that  any 
deformity  affecting  the  symmetry  of  the  chest  will  affect 
the  relative  resonance  on  the  two  sides ;  and  that  a  devia- 
tion from  symmetry  attributable  to  the  position  of  the 
patient  will  occasion  a  disparity  on  percussion.  In  the 
third  place,  the  rules  for  the  practice  of  percussion  must 
be  kept  in  mind,  in  order  to  avoid  producing  a  disparity 
by  the  non-observance  of  these  rules  {vide  p.  51).  Nor- 
mal resonance  on  percussion  on  the  two  sides  is  a  strong 
point  for  the  exclusion  of  incipient  phthisis. 

The  direct  respiratory  signs  in  incipient  phthisis  are 
the  broncho-vesicular  respiration  and  weakened  vesicular 
murmur.  To  these  is  to  be  added  a  localized  inter- 
rupted or  wavy  respiratory  murmur  as  an  occasional 
sign.  Of  course,  familiarity  with  the  characters  of 
the  broncho- vesicular  respiration  is  indispensable — the 
combination  of  the  vesicular  and  the  tubular  quality  in 
the  inspiratory  sound,  with  the  pitch  raised  in  proportion 
to  the  amount  of  tubularity,  and  the  expiratory  sound 
more  or  less  prolonged,  high,  and  tubular.  Not  infre- 
quently the  only  appreciable  morbid  modification  is  di- 
minished intensity  of  the  murmur.  When  this  sign  is 
present,  it  is  probable  that  the  lack  of  intensity  is  the 
reason  for  the  absence  of  the  characters  of  the  broncho- 
vesicular  modifications,  that  is,  the  latter  sign  would 
have  been  present  were  the  respiratory  sounds  more  in- 
tense. 

The  direct  vocal  signs  in  incipient  phthisis  are,  in- 
creased  vocal  resonance,  increased    bronchial  whisper, 


piiTOisis.  175 

and  increased  fremitus.  The  other  direct  signs  may  be 
present  without  an  appreciable  morbid  increase  of  the 
vocal  resonance  or  fremitus.  The  increased  whisper  may 
also  be  wanting,  but  more  rarely  than  the  two  other  vocal 
signs. 

In  deciding  on  the  presence  or  absence  of  each  and 
all  of  these  direct  signs,  it  is  essential  to  know  and  to 
judge  correctly  of  the  disparity  between  the  two  sides  of 
the  chest  at  the  summit  in  health.  Normally  the  reso- 
nance on  percussion  at  the  summit  on  the  right  side  is 
slightly  dull  as  compared  with  the  left  side;  the  inspi- 
ratory sound  on  this  side  has  some  tubularity  in  quality, 
and  is  somewhat  raised  in  pitch  ;  the  expiratory  sound 
may  be  more  or  less  prolonged,  high,  and  tubular;  the 
vocal  resonance  on  the  right  side  is  always  greater,  the 
same  being  true  of  fremitus  ;  the  bronchial  whisper  is 
louder  on  the  right  side,  and  the  intensity  of  the  re- 
spiratory murmur  is  a  little  less  on  this  side.  Whenever 
it  is  a  question  as  to  a  small  phthisical  affection  at  or 
near  the  a[)ex  of  the  right  lung,  it  is  a  matter  of  expe- 
rience and  judgment  to  decide  if  the  disparity  in  respect 
of  these  points  be  greater  than  normal,  and  it  is  not 
always  easy  to  come  at  once  to  a  decision.  From  the 
want  of  a  pro[)er  appreciation  of  the  several  points  of 
disparity  in  health,  it  is  not  uncommon  for  an  erroneous 
diagnosis  of  phthisis  to  be  based  thereon.  Appreciating 
the  normal  points  of  disparity,  it  is  obviously  eiisier  to 
determine  that  the  sevei-al  direct  signs  of  incipient 
phthisis  are  present  at  the  left  than  at  the  right  sum- 
mit; relative  dulness  on  percussion,  broncho-vesicular 
or  weakened  respiration,  increased  vocal  resonance,  whis- 
per, and  fremitus,  at  the  left  summit  are,  of  course,  al- 
ways abnormal. 


176  PHYSICAL    DIAGNOSIS. 

In  connection  with  the  foregoing  direct  signs  may  be 
mentioned  another  sign  which  is  often  available,  namely, 
an  abnormal  transmission  of  the  heart-sounds.  This  sign 
is  available  only  in  the  central  portion  of  the  infra-cla- 
vicular region.  A  slight  degree  of  solidification  of  the 
summit  of  one  lung  renders  the  heart-sounds  more  audi- 
ble in  the  situation  just  named.  It  is  of  assistance  in 
determining  this  sign  to  be  familiar  with  the  following 
points  of  disparity  which  exist  in  health  :  on  the  right 
side  the  second  sound  of  the  heart  is  somewhat  more 
audible  than  on  the  left  side,  and  on  the  leftside  the  first 
sound  is  a  little  louder  than  on  the  right  side.  Hence, 
if  the  first  sound  be  better  conducted  on  the  right  than 
on  the  left  side,  it  is  abnormal;  and  if  the  second  sound 
be  louder  on  the  left  side,  it  is  abnormal.  This  sign  is 
always  to  be  taken  in  connection  with  other  direct  signs  ; 
it  gives  greater  diagnostic  strength  to  the  latter,  but  it  is 
by  no  means,  in  itself,  sufficient  for  the  diagnosis. 

Corroborative  evidence  of  incipient  phthisis  may  be 
obtained  by  the  presence  of  accessory  signs.  These  are  : 
First,  fine  bubbling  or  the  subcrepitant  rale  at  the  sum- 
mit on  one  side.  This  sign  denotes  a  circumscribed 
capillary  bronchitis,  and  this,  at  the  summit  on  one  side, 
is  usually  associated  with  phthisis.  Second,  a  crepitant 
rale  at  the  summit  on  one  side  denotes  a  circumbscribed 
pneumonia  which  is  usually  secondary  to  plithisis.  Third, 
a  pleuritic  friction-sound  limited  to  the  summit  on  one 
side  is  evidence  of  a  dry  circumscribed  pleurisy  which 
occurs  often  in  the  early  stage  of  phthisis.  Fourth,  in- 
determinate rales,  crumpling,  and  crackling,  are  signifi- 
cant of  phthisis  if  limited  to  the  summit  on  one  side. 
These  rales,  it  is  to  be  recollected,  are  sometimes  found 
in  healthy  persons  on  forced  breathing,  especially  if  the 


PHTHISIS.  177 

binaural  stethoscope  be  employed.  If  they  be  normal 
they  are  found  on  both  sides.  The  accessory  signs  are 
not  sufficient  for  a  positive  diagnosis  if  they  exist  alone  ; 
but  they  are  to  be  considered  as  corroborating  the  evi- 
dence derived  from  the  direct  signs,  together  with  the 
symptoms  and  history.  It  is  of  service  often  in  bring- 
ing out  the  rales  to  cause  the  patient  to  cough. 

As  regards  differential  diagnosis,  the  affections  with 
which  incipient  phthisis  is  likely  to  be  confounded  are 
chronic  bronchitis  and  moderate  emphysema.  With 
respect  to  the  first  of  these  affections,  namely,  bronchitis, 
the  differentiation  must  depend  on  the  presence  or  the 
absence  of  positive  signs  of  phthisis ;  in  other  words, 
phthisis  is  either  diagnosticated  or  excluded.  The 
physical  signs  in  cases  of  moderate  emphysema  some- 
times lead  to  the  error  of  supposing  this  affection  to  be 
phthisis.  Owing  to  the  relatively  greater  intensity  of 
the  resonance  on  percussion  at  the  left  summit,  dulness 
is  thought  to  exist  at  the  right  summit,  and  a  prolonged 
expiration,  with  the  normally  greater  vocal  resonance  at 
the  right  summit,  are  set  down  as  signs  of  phthisis.  This 
error  may  be  avoided  by  a  careful  study  of  the  signs  of 
emphysema  and  the  normal  disparity  in  respiration,  vocal 
resonance,  and  fremitus,  existing  between  the  two  sides 
of  the  chest. 

The  physical  diagnosis  of  a  phthisical  affection  which 
is  considerable  or  moderate  in  amount,  is,  in  most  cases, 
an  easy  problem.  Inspection  often  furnishes  marked 
signs.  The  upper  anterior  portion  of  the  chest  on  one 
side  is  depressed  or  flattened,  and  the  superior  costal 
movements  of  respiration  are  diminished,  the  chest  else- 
where  being  symmetrical   in  both   size   and     motions. 


178  PHYSICAL    DIAGNOSIS* 

There  is  more  or  less  marked  dulness  on  percussion  at 
the  upper  part  of  the  chest  on  the  affected  side.  Some- 
times the  diminished  resonance  is  tympanitic  in  quality 
(tympanitic  dulness)  without  the  existence  of  cavities,  the 
resonance  being  conducted  from  the  primary  and  second- 
ary bronchial  tubes.  The  respiration  is  either  bronchial, 
or  broncho-vesicular,  approximating  more  or  less  to  the 
bronchial.  Occasionally,  however,  the  respiratory  sounds 
are  too  feeble  for  their  characters  to  be  appreciated.  There 
is  either  bronchophony,  or  the  vocal  resonance  is  notably 
increased  without  the  bronchophonic  characters.  The 
whisper  is  either  distinctly  bronchophonic  or  it  is  notably 
increased  in  intensity,  high  in  pitch,  and  tubular  in 
quality.  Vocal  fremitus  is  often  increased.  Moist 
bronchial  rales,  coarse  or  fine,  are  generally  present. 
With  these  diagnostic  signs  on  one  side,  the  signs  of  a 
smaller  amount  of  disease  are  generally  present  on  tiie 
other  side. 

In  some  cases  of  a  moderate  phthisical  affection,  the 
judgment  may  be  confused  by  the  resonance  on  percus- 
sion being  increased  or  vesiculo-tympaniticon  theaffected 
side.  This  sign  denotes  the  coexistence  of  emphysema- 
tous lobules  (vicarious  em})hysema)  developed  in  the  pro- 
gress of  phthisis.  The  diagnosis  of  the  latter  affection 
is  then  to  be  based  on  the  signs  obtained  by  auscultation. 

In  advanced  ])hthisis  the  physical  diagnosis  of  the 
disease  is  sufffciently  easy.  The  signs  distinctive  of  this 
stage  of  the  disease  are  tliose  which  denote  pulmonary 
cavities,  namely,  tympanitic  resonance  on  percussion 
within  a  circumscribed  space;  cracked-metal  or  amphoric 
resonance;  cavernous  respiration;  cavernous  whisper  and 
sometimes  pectoriloquy  ;  amphoric  respiration  and  voice, 


FIBROID    PHTHISIS,    ETC.  179 

and  gurgling  [vide  Chapter  V.  for  description  of  these 
signs). 

The  cavernous  signs  are  generally  associated  with  the 
signs  of  solidification.  In  somecases,  however,  in  which 
the  disease  has  been  non-progressive  and  retrogressive, 
the  cavernous  signs  are  present  without  the  signs  which 
denote  solidification  of  lung. 

Fibroid  Phthisis— Interstitial  Pneumonia,  or  Cirrhosis 

of  Lung. 

In  this  affection  the  physical  conditions  are,  solidifica- 
tion from  hyperplasia  of  the  interstitial  pulmonary  tissue, 
dilatation  of  bronchial  tubes  (bronchiectasis)  and  dimin- 
ished volume  of  the  lung  affected.  The  affection,  as  a 
rule,  is  either  limited  to  or  especially  marked  on  one 
side.  The  whole  of  a  lung,  or  only  a  portion  of  it,  may 
be  affected.     Bronchitis  always  coexists. 

There  is  notable  dulness  on  percussion,  the  diminished 
resonance  being  sometimes  tympanitic.  The  degree  of 
resonance  may  vary  at  different  examinations,  owing  to 
differences  in  the  amount  of  morbid  products  within  the 
bronchial  tubes.  The  respiration  is  bronchial,  or  bron- 
cho-vesicular. At  times,  from  obstruction  of  bronchial 
tubes,  it  may  be  suppressed.  Bronchophony  and  in- 
creased vocal  resonance  are  the  vocal  signs,  together  with 
the  corresponding  whispering  signs.  The  side  of  the  chest 
wdiioh  is  chiefly  or  exclusively  affected  becomes  contracted 
either  entirely  or  in  part,  resembling  in  this  respect  the 
appearances  after  chronic  pleurisy. 

With  these  signs  the  affection  is  to  be  differentiated 
from  the  ordinary  form  of  phthisis,  by  reference  to  points 
pertaining  to  the  symptoms  and  history. 


180  PHYSICAL    DIAGNOSIS. 

Diaphragmatic  Hernia. 

The  presence  of  more  or  less  of  the  abdominal  viscera 
within  the  thoracic  cavity  in  consequence  of  a  congenital 
deficiency  of  a  portion  of  the  diaphragm,  or  perforation 
from  accidents,  or  enlargement  of  the  natural  openings, 
gives  rise  to  certain  anomalous  signs,  namely,  a  tympa- 
nitic resonance,  variable  at  different  times  owing  to  differ- 
ences as  regards  the  quantity  of  gas  within  the  viscera; 
absence  of  the  respiratory  murmur  from  the  base  of  the 
chest  upward,  the  height  proportional  to  the  space  occu- 
pied by  the  abdominal  organs,  and  the  intestinal  sounds 
emanating  from  within  the  chest,  not  conducted  from 
below. 

This  extremely  rare  affection  can  only  be  confounded 
with  pneumothorax.  The  latter  affection  is  to  be  ex- 
cluded by  the  absence  of  its  diagnostic  signs,  irrespec- 
tive of  the  tympanitic  resonance  on  percussion. 


THE    UEAllT.  181 


CHAPTER  VII. 

THE  PHYSICAL  CONDITIONS  OF  THE  IIEAKT  IN 
HEALTH  AND  DISEASE.  THE  HEAKT-SOUNDS  AND 
CAKDIAC  MURMURS. 

Pliysical  conditions  of  the  heart  in  health  : — Bounflaries  of  the  prse- 
cordia — Normal  situation  of  the  apex-beat — Boundaries  of  the  deep 
and  of  the  superficial  cardiac  space — Relations  of  the  aorta  and  the 
pulmonary  artery  to  the  walls  of  the  chest — The  heart-sounds— Char- 
acters distinguisliing  the  first  and  the  second  sound — Mechanism  of 
the  xn'oduction  of  the  heart-sounds — Auscultation  of  the  pulmonic 
and  the  aortic  second  sound  separately — Movements  of  the  auricles 
and  ventricles  in  relation  to  each  other — Physical  conditions  of  the 
heart  in  disease ;  Enlargement  of  the  heart — Hypertrophy  and  di- 
latation— Abnormal  imputees  of  the  heart,  and  modifications  of  the 
apex -beat — Valvular  lesions — Roughness  of  the  pericardial  surfaces 
— Liquid  within  the  pericardial  sac — Abnormal  modifications  of  the 
heart-sounds — Reduplication  of  heart-sounds — Cardiac  murmurs — 
Normal  and  abnormal  blood-currents  within  the  heart,  and  their  re- 
lations with  the  heart-sounds — Mitral  direct  murmur — Mitral  regur- 
gitant murmur — Mitral  systolic  non-regurgitant,  or  intra-ventricu- 
lar  murmur — Aortic  direct  murmur — Aortic  regurgitant  murmur, 
and  an  Aortic  diastolic  non-regurgitant  murmur — Coexisting  endo- 
cardial murmurs — Tricuspid  direct  murmur — Tricuspid  regurgitant 
murmur — Pulmonic  direct  murmur — Pulmonic  regurgitant  murmur 
— Facts  of  practical  importance  in  relation  to  endocardial  murmurs 
— Pericardial  or  friction  murmur. 

Before  entering  upon  the  study  of  the  physical  diag- 
nosis of  the  diseases  of  the  heart,  the  student  must  be 
familiar  with  its  anatomy  and  physiology.  For  a  de- 
scription of  the  structure  and  functions  of  this  organ,  he 
is  referred  to  anatomical  and  physiological  treatises. 
The  plan  of  this  work  embraces  the  anatomical  relations 
of  the  heart  and  the  space  which  it  occupies  within  the 

16 


182  THE    HEART. 

chest,  as  physical  conditions  of  health  determinable  by 
normal  signs,  together  with  the  heart-sounds.  Having 
briefly  stated  these  conditions  of  health,  the  morbid  phys- 
ical conditions  which  may  be  ascertained  by  percussion, 
auscultation,  and  other  methods  of  physical  exploration, 
will  be  considered.  The  latter  heading  will  inckule  an 
account  of  the  cardiac  murmurs. 

The  Physical  Conditions  of  the  Heart  in  Health. 

The  Prcecordia — The  Superficial  and  the  Deep  Cardiac 
Space. — The  area  on  the  surface  of  the  chest  correspond- 
ing to  the  space  which  the  heart  occupies  within  the 
chest,  is  the  prsecordial  region,  or  the  prsecordia.  The 
upper,  lower,  and  two  lateral  boundaries  of  this  region 
must  be  memorized.  The  upper  boundary  is  the  third  rib, 
the  lower  is  a  horizontal  line  passing  through  the  fifth  in- 
tercostal space  ;  the  left  lateral  boundary  is  at,  or  a  little 
within,  a  vertical  line  passing  through  the  nipple,  the 
linea  mammillarisj  and  the  right  lateral  boundary  is  rep- 
resented by  a  vertical  line  situated  about  a  finger's  breadth 
to  the  right  of  the  right  margin  of  the  sternum.  As 
the  volume  of  the  heart  varies,  within  certain  limits,  in 
different  healthy  persons,  the  boundaries  of  the  prse- 
cordia  are,  of  course,  not  always  exactly  the  same.  The 
foregoing  statements  are  sufficiently  accurate  for  practical 
purposes. 

The  horizontal  line  representing  the  lower  boundary 
of  the  praecordia  intersects  the  point  where  the  apex- 
beat  of  the  heart  is  felt.  The  normal  situation  of  the 
apex-beat  must  be  recollected.  In  most  healthy  persons 
the  apex-beat  is  felt  in  the  fifth  intercostal  space,  a  little 
within  the  linea  mammillaris.  This  is  assuming  the 
persons  to  be  sitting  or  standing;  in  recumbency  on  the 


CONDITIONS    OF    HEART    IN    HEALTH.  183 

back  tlie  beat  sonietinies  rises  to  the  fourth  intercostal 
space,  and  it  is  sometimes  found  in  the  fourth  space  in 
the  sitting  or  standing  position  of  the  body.  The  dis- 
tance from  the  linea  mammillaris  vjiries  in  different 
healthy  persons;  it  is  sufficiently  accurate  to  say  it  is  a 
little  within  that  line.  The  force  of  the  apex-beat  varies 
much  in  different  healthy  persons,  owing  to  other  causes 
than  the  power  of  the  heart's  action,  such  as  the  amount 
of  muscular  substance  and  fat  in  that  situation,  the  width 
of  the  intercostal  space,  the  convexity  of  the  chest,  the 
relation  to  the  left  luno^  etc.  Allowance  is  to  be  made 
for  these  variations  in  determining  the  abnormal  modifi- 
cations of  the  force  of  the  beat,  which  belong  among 
the  physical  signs  of  disease. 

Within  a  portion  of  the  }3r?ecordia  the  heart  is  un- 
covered of  lung,  and  in  the  remaining  portion  lung  in- 
tervenes between  the  heart  and  the  walls  of  the  chest. 
The  former  of  these  portions  is  called  the  superficial,  and 
the  latter  is  called  the  deep  cardiac  space.  The  deep 
cardiac  space  on  the  right  side  extends  to  the  median 
lino.  On  the  left  side  the  lung  recedes  at  a  point  on  the 
median  line  on  a  level  with  the  cartilage  of  the  fourth 
rib,  and  the  anterior  border  of  the  upper  lobe  makes  an 
outward  curve,  returning  inward  at  or  near  the  apex  of 
the  heart.  This  leaves  the  heart  uncovered  within  an 
area  which,  for  practical  purposes,  may.  be  represented 
by  a  right-angled  triangle,  the  hypothenuse  extending 
from  the  median  line  on  a  level  with  the  costal  cartilage 
of  the  fourth  rib  to  the  apex  of  the  heart ;  the  right 
angle  formed  by  the  median  line  and  the  horizontal  line 
which  forms  the  lower  boundary  of  the  prsecordia. 

The  limits  of  the  superficial  cardiac  space  may  be  easily 
defined  by  percussion.     It  is  only  necessary  to  ascertain 


184  THE    HEART. 

the  curved  line  formed  by  the  receding  anterior  border 
of  the  upper  lobe  of  the  left  lung.  A  distinct,  although 
not  great,  dulness  on  percussion  marks  this  border  of 
the  lung.  The  border  of  the  lung  is  as  distinctly  marked 
by  the  abrupt  diminution  of  the  vocal  resonance,  if  aus- 
cultation be  made  with  the  stethoscope.  The  outer 
boundaries  of  the  deep  cardiac  space  may  also  be  deter- 
mined by  percussion  ;  distinct,  although  slight  dulness 
marks  the  limits  of  the  prsecordia.  Defining  thus  the 
boundaries  of  the  prsecordia  and  of  the  superficial  car- 
diac space  in  healthy  persons,  makes  a  good  practical 
exercise  in  percussion. 

Relations  of  the  Aorta  and  Pulmonary  Artery  to  the 
Walls  of  the  Chest. — The  base  of  the  heart,  especially  in 
connection  with  auscultatory  signs,  is  generally  consid- 
ered to  be  at  the  second  intercostal  space  near  the  ster- 
num, this  situation  being,  in  reality,  just  above  the  base. 
In  this  situation  sounds  produced  at  the  aortic  and  the 
pulmonic  orifice  are  best  studied,  either  in  health  or 
disease.  With  reference  to  these  sounds,  the  anatomical 
relations  of  the  aorta  and  the  pulmonary  artery  to  the 
right  and  the  left  second  intercostal  space  are  of  im- 
portance. If  the  stethoscope  be  applied  in  the  second 
intercostal  space  on  the  right  side,  close  to  the  sternum , 
it  is  very  near  the  aorta,  and  sounds  produced  at  the 
aortic  orifice  are  best  heard  in  this  situation.  If  the 
stethoscope  be  applied  in  the  second  intercostal  space  on 
the  left  side,  it  is  very  near  the  pulmonary  artery,  and 
the  sounds  produced  at  the  pulmonic  orifice  are  best 
heard  in  this  situation.  Reference  will  be  made  to  these 
two  situations  in  giving  an  account  of  the  heart-sounds 
in  health  and  disease,  and  of  adventitious  sounds  or 
murmurs. 


CONDITIONS    OP    HEART    IN    HEALTH.  185 

The  Heart-sounds. — Tho  characters  wliich  distinguish 
respectively  the  first  and  the  second  sound  of  the  heart, 
are  to  be  studied  preparatory  to  the  study  of  the  abnor- 
mal modifications  which  are  important  physical  signs  of 
disease.  It  is  essential  also  to  be  able  always  to  make  the 
distinction  practically  between  the  first  and  the  second 
sound  in  order  to  connect  with  each  sound  separately 
cardiac  murmurs.  The  conventional  sense  of  the  term 
heart-sounds,  as  distinguished  from  cardiac  murmurs, 
must  be  borne  in  mind.  The  cardiac  murmurs  are  ad- 
ventitious sounds ;  they  are  never  merely  abnormal 
modifications  of  the  heart-sounds,  but  they  are  new 
sounds  added  to  these. 

The  two  heart-sounds  follow  in  a  certain  rhvthmical 
order,  and,  in  health,  this  suffices  for  the  recognition  of 
each.  It  answers  all  practical  purposes  to  say  that  the 
first  and  the  second  sound  follow  each  other  after  an  in- 
terval which  is  just  appreciable,  this  interval  being  the 
short  pause  of  the  heart.  After  the  two  sounds,  an  in- 
terval is  readily  a])preciable,  called  the  long  pause  of 
the  heart.  It  is  not  necessary  to  carry  in  the  memory 
the  exact  relative  duration  of  each  of  the  sounds  and 
each  of  the  intervals.  The  fractions  of  a  unit,  in  fact, 
do  not  express  the  length  of  the  sounds  and  intervals  as 
correctly  as  less  definite  expressions,  inasmuch  as  the 
figures  represent  only  the  mean  of  variations  within  the 
limits  of  health.  It  is  sufficiently  definite  to  say  that, 
with  the  ear  or  stethoscope  applied  over  the  situation  of 
the  apex-beat,  the  first  sound  is  longer  than  the  second, 
louder,  lower  in  pitch,  and  has  a  quality  which  may  be 
called  booming.  Per  conbrt,  the  second  sound  is  shorter, 
weaker,  higher  in  pitch,  and  has  a  quality  which  may 
be  called  valvular  or  clicking.     Aside  from  the  relative 


186  THE    HEART. 

lengtli  of  tlie  two  sounds,  tlie  other  characters  are  more 
or  less  marked  in  different  healthy  persons. 

These  distinctive  cliaracters  of  the  heart-sounds  are 
apparent  when  the  ear  or  stethoscope  is  applied  over 
the  apex.  At  the  base  of  the  heart,  that  is,  in  the 
second  intercostal  space  near  the  sternum,  the  characters 
of  the  first  sound  are  not  the  same.  The  second  sound 
in  this  situation  is  louder  than  the  first.  This  sound  is 
said  to  be  accentuated  at  the  base,  the  first  sound  being 
accentuated  at  the  apex.  Moreover  the  first  sound  at 
the  base  may  not  be  longer  than  the  second ;  it  loses 
more  or  less  of  its  booming  quality,  the  pitch  remaining 
lower  than  that  of  the  second  sound.  Removing  the  ear 
or  the  stethoscope  a  certain  distance  from  the  apex  in 
any  direction,  occasions  ^milar  changes  in  the  characters 
of  the  first  sound.  The  interposition  of  several  thick- 
nesses of  a  napkin  has  the  same  effect. 

From  the  differential  characters  over  the  apex,  and 
the  rhythm  in  other  situations,  there  is  no  difficulty  in 
distinocuishino;  the  first  from  the  second  sound  in  health. 
In  cases  of  disease,  however,  owing  to  disturbance  of  the 
rhythm,  modifications  of  the  characters  of  the  first  sound, 
and  the  absence  sometimes  of  one  of  the  sounds,  other 
means  of  recognition  must  be  resorted  to.  If  the  apex- 
beat  can  be  felt,  this  offers  a  ready  way  for  recognizing 
the  first  sound — the  sound  which  is  synchronous  with 
the  apex-beat  is,  of  course,  the  first  sound.  This  mode 
is  not  always  available,  inasmuch  as  the  apex-beat  can- 
not always  be  felt.  Another  mode  is  always  available, 
namely,  feeling  the  carotid  pulse.  The  carotid  pulse 
is  synchronous  with  the  first  sound,  whereas  there  is  a 
slight  interval  between  this  sound  and  the  radial  pulse. 

The  student  is  aided  in  comprehending  certain  physi- 


CONDITIONS    OF    UEART    IN    HEALTH.  187 

cal  signs  by  taking  into  view  the  mechanism  of  the  pro- 
duction of  the  heart-sounds.  The  second  sound  is  pro- 
duced by  the  sudden  forcible  closure  of  the  aortic  and 
the  pulmonic  valves.  This  closure  is  caused  by  a  retro- 
grade movement  of  the  columns  of  blood  in  the  aorta 
and  pulmonary  artery,  directly  the  ventricular  systole  is 
ended.  The  retrograde  movement  is  due  to  the  recoil  of 
the  coats  of  the  arteries  which  have  been  dilated  by  the 
column  of  blood  moving  onward  during  the  ventricular 
systole.  This  recoil  causes  regurgitation  into  the  ven- 
tricle when  either  the  aortic  or  the  pulmonic  valve  is 
rendered  incompetent  by  lesions.  The  mechanism  of  the 
first  sound  is  less  simple.  This  sound  is  in  part  due  to 
the  forcible  tension  of  the  auriculo- ventricular  valves, 
caused  by  the  systole  of  the  veptricles.  In  this  way  is 
produced  a  valvular  element  of  the  first  sound.  That 
the  impulsion  of  the  heart  against  the  walls  of  the  chest 
furnishes  another  element,  seems  demonstrable.  To  this 
element  of  impulsion  the  first  sound  is  indebted  for  its 
greater  intensity,  as  compared  with  the  second  sound,  its 
length,  and  its  booming  quality.  This  is  shown  by  the 
fact,  already  stated,  that  when  auscultation  is  made  at  a 
certain  distance  from  the  apex,  these  characters  are 
eliminated,  and  by  the  fact  that  diseases  which  diminish 
or  arrest  the  Impulsion  movements  of  the  heart  produce 
the  same  modifications.  The  valvular  element  of  the 
first  sound  Is  weaker  than  the  second  sound,  a  fact  which 
at  first  occasions  surprise  when  the  difference  in  size 
between  the  aortic  and  pulmonic  and  the  auriculo-ven- 
tricular  valves  is  considered.  The  explanation  of  this 
apparent  incongruity  is  as  follows:  the  aortic  and  pul- 
monic sejyments  at  the  end  of  the  ventricular  svstole  are 
in  contact  with  the  arterial  walls,  and  are  expanded  when 


188  THE    HEART. 

the  recoil  of  the  latter  follows.  On  the  other  hand, 
when  the  ventricular  systole  takes  place  in  health,  the 
auriculo-ventricular  valves  are  not  in  contact  with  the 
walls  of  the  ventricles,  but  they  are  floated  out,  and  the 
orifices  are  nearly  or  quite  closed  ;  the  movement  of  the 
blood,  therefore,  in  the  systole  only  renders  these  valves 
tense.  The  second  sound,  in  other  words,  is  due  to  the 
expansion  of  the  sigmoid  valves  of  the  aorta  and  pulmo- 
nary artery,  whereas,  the  valvular  element  of  the  first 
sound  is  due  to  the  tension  of  the  auriculo-ventricular 
valves.  The  foregoing  points  relating  to  the  heart-sounds 
were  contained  in  my  prize  essay  "  On  the  Clinical 
Study  of  the  Heart-Sounds  in  Health  and  Disease,'^ 
published  in  the  Transactions  of  the  American  Medical 
Association  in  1858.^ 

A  point  in  relation  to  the  second  sound  of  the  heart 
has  an  interesting  and  important  bearing  on  auscultation 
in  disease,  namely,  the  study  of  this  sound  as  produced 
at  the  aortic  and  the  pulmonic  orifices  separately.  Re- 
calling the  anatomical  relations  of  the  aorta  and  the 
pulmonary  artery  to  the  walls  of  the  chest,  if  the  stetho- 
scope be  applied  in  the  second  intercostal  space  on  the 
right  side  close  to  the  sternum,  the  characters  of  the 
second  sound  are  derived  chiefly  from  the  aortic  valve, 
and  if  the  stethoscope  be  applied  in  the  second  intercos- 
tal space  on  the  left  side  close  to  the  sternum,  the  char- 
acters of  the  second  sound  are  derived  chiefly  from  the 
pulmonic  valve.  The  correctness  of  this  statement  is 
proved  by  differences  in  the  characters  of  the  sound  on 
two  sides  in  health,  and  by  the  modifications  in  cases  of 
disease.     These  morbid  modifications  will  enter  into  the 

1  Vide,  also,  "  Treatise  on  Diseases  of  the  Heart,"  first  edition, 
1860;  second  edition,  1870. 


CONDITIONS    OF    HEART    IN    UEALTH.  189 

physical  diagnosis  of  cardiac  affections.  In  health  the 
aortic  second  sound  is  somewhat  louder,  higher  in  jjitch, 
and  the  valv^ilar  quality  more  marked  than  the  pulmonic 
second  sound.  The  student  should  verify  these  points  of 
difference  by  the  study  of  the  second  sound  in  the  two 
situations  just  named.  In  order  for  the  comparison  to 
be  a  fair  one  in  health,  and  available  in  the  diagnosis  of 
disease,  the  normal  anatomical  relations  to  the  walls  of 
the  chest,  of  tiie  aorta,  and  pulmonary  artery  must  be 
preserved.  These  relations  are  affected  by  changes  in 
the  symmetry  of  the  chest,  and  sometimes  by  enlarge- 
ment of  the  heart.  The  lungs  must  also  be  free  from 
disease;  otherwise,  the  conduction  of  the  sounds  wmU  be 
abnormal. 

The  movements  of  the  auricles  and  the  ventricles  are 
to  be  kept  in  mind  with  reference  to  the  comprehension 
of  certain  physical  signs  of  disease.  Points  of  especial 
importance  are  the  contraction  of  the  auricles  in  the 
latter  part  of  the  long  pause  of  the  heart,  preceding  the 
ventricular  systole,  and  the  twisting  of  the  heart  from 
left  to  right  in  the  systole,  this  movement  being  reversed 
in  the  diastole.  In  these  systolic  and  diastolic  twisting 
movements,  tlie  pericardial  surfaces  move  upon  each, 
but  in  health  noiselesslv  owino^  to  their  smoothness  and 
moisture.  The  movements  occasion  an  auscultatory 
sound  when  the  surfaces  are  roughened  by  the  presence 
of  lymph.  Other  points  are  the  size  of  the  pericardial 
sac,  that  is,  its  capability  of  holding  when  filled,  but  not 
dilated,  from  fifteen  to  twenty  ounces  of  liquid,  and  its 
attachment,  not  to  the  base  of  the  heart,  but  to  the 
vessels  above  the  base. 


190  THE    HEART. 

Physical  Conditions  of  the  Heart  in  Disease. 

The  physical  conditions  of  the  heart  in  disease,  which 
are  determinable  by  physical  exploration,  are,  1st,  en- 
largement of  the  heart;  2d,  abnormal  impulses  and 
modifications  of  the  apex-beat;  3d,  valvular  lesions; 
4th,  roughness  of  the  pericardial  surfaces  ;  and,  5th, 
liquid  within  the  pericardial  sac.  Having  considered 
tiiese  conditions,  an  account  of  abnormal  modifications 
of  the  heart-sounds  and  cardiac  murmurs  will  conclude 
this  chapter. 

Enlargement  of  the  Heart. — Enlargement  of  the  heart 
may  be  slight,  moderate,  great,  or  very  great,  these  terms 
expressing  different  degrees  of  enlargement  with  suffi- 
cient precision  for  clinical,  purposes.  In  cases  of  very 
great  enlargement,  the  space  within  the  chest  which  the 
heart  occupies  may  be  from  four  to  five  times  larger  than 
in  health.  The  situation  of  the  base  of  the  heart  re- 
mains but  little,  or  not  at  all,  changed  in  cases  of  en- 
largement ;  the  increased  space  which  the  heart  occupies 
is  therefore  downward.  The  increased  space  extends 
much  more  to  the  left  than  to  the  right;  the  left  border 
of  the  heart,  in  proportion  to  the  enlargement,  is  carried 
beyond  the  mammary  line  on  the  left  side,  whereas,  the 
right  border  is  carried  comparatively  but  little  beyond 
the  normal  right  lateral  boundary  of  the  praecordiaeven 
when  the  enlargement  is  very  great.  The  superficial 
cardiac  space  is  enlarged  in  proportion  to  the  enlarge- 
ment of  the  heart ;  the  organ  pushes  to  the  left  the  re- 
ceding anterior  border  of  the  upper  lobe  of  the  left 
lung,  and  is  proportionately  in  contact,  uncovered  of  lung, 
with  the  walls  of  the  chest.  The  apex  of  the  heart  is 
lowered  in  proportion  to  the  enlargement,  and  it  is  car- 
ried more  or  less  to  the  left  of  its  normal  situation.     It 


CONDITIONS    OF    HEART    IN    DISEASE.  191 

may  be  lowered  to  the  sixtli,  seventli,  eighth,  or  ninth 
intercostal  space.  The  enlargement  of  the  heart  is  rarely 
equal  in  all  its  parts.  The  ventricular  enlargement  may 
be  entirely  or  chiefly  of  either  the  right  or  the  left  ven- 
tricle. Enlargement  of  the  right  ventricle  tends  to  carry 
the  right  side  of  the  heart  more  to  the  right  than  when 
the  left  ventricle  is  enlarged.  The  situation  of  the  apex 
is  also  affected  by  the  parts  of  the  heart  in  which  the 
enlargement  predominates.  The  apex  is  carried  further 
to  the  left  of  its  normal  situation,  other  things  being 
equal,  when  the  enlargement  predominates  on  the  right 
side  of  the  heart ;  and  it  is  lowered  without  being  carried 
far  to  the  left  when  the  enlargement  of  the  left  ventricle 
predominates.  The  apex  of  the  organ  in  cases  of  con- 
siderable or  of  great  enlargement  becomes  changed  in 
form  ;  it  is  rounded  or  blunted.  This  change  is  most 
marked  when  enlargement  of  the  right  ventricle  pre- 
dominates. All  these  points  are  of  importance  with 
reference  to  the  comprehension  of  the  physical  signs  of 
enlargement  of  the  heart. 

Enlargement  of  the  heart  may  be  entirely  due  either 
to  hypertrophy  or  to  dilatation  (simple  hypertrophy  and 
simple  dilatation).  If,  however,  the  enlargement  be 
sufficient  to  occasion  notable  disturbance  of  the  circu- 
lation, both  these  forms  of  enlargement  are  combined, 
but,  as  a  rule,  one  or  the  other  form  predominating,  so 
that,  of  the  cases  of  diseases  of  the  heart  which  come 
under  medical  treatment,  the  majority  are  cases  of  either 
enlargement  with  predominant  hypertrophy  or  enlarge- 
ment with  predominant  dilatation. 

These  widely  different  physical  conditions  are  con- 
cerned especially  in  the  abnormal  impulses  and  modi- 


192  THE    HEART. 

fications  of  the  apex-beat,  as  well  as,  also,  the  heart- 
sounds. 

Abnormal  Im.puhes  of  the  Heart,  and  Modifications 
of  the  Apex-beat. — The  abnormal  situation  of  the  apex 
of  the  heart  when  enlarged  has  been  stated.  Generally 
the  situation  is  determinable  by  the  apex-beat.  It  has 
been  seen  that  in  health  the  beat  is  sometimes  not  appre- 
ciable by  the  touch,  owing  to  the  thickness  of  the  soft 
parts,  and  the  conformation  of  the  thorax,  and,  for  these 
reasons,  the  force  of  the  beat  varies  much  in  different 
healthy  persons.  Exclusive  of  normal  variations,  the 
beat  is  generally  strong  and  prolonged  in  proportion  as 
the  heart  is  enlarged  by  hypertrophy.  There  are  excep- 
tions to  this  statement,  which  are  to  be  explained  by  the 
altered  form  of  the  apex ;  when  it  loses  its  pointed  form 
it  does  not  so  readily  come  into  contact  with  the  walls  of 
the  chest  in  an  intercostal  space,  and,  hence,  the  beat 
may  be  weak  although  the  ventricular  systole  be  abnor- 
mally strong.  On  the  other  hand,  the  apex-beat  is 
weakened  by  dilatation,  and  it  may  be  wanting  as  a  re- 
sult of  diminished  strength  of  the  systole  of  the  ven- 
tricles. The  apex-beat  is  also  abnormally  weak  in  fatty 
degeneration  and  softening  of  the  heart,  as  well  as  in 
functional  debility  of  the  organ  incident  to  other  diseases 
than  those  of  the  heart. 

If  there  be  considerable  or  great  enlargement,  tiie 
heart  being  in  contact  with  the  walls  of  the  chest  over  a 
larger  area  than  in  health,  impulses  other  than  the  apex- 
beat  are  generally  apparent  to  the  eye  and  touch.  Not 
infrequently  impulses  are  appreciable  in  each  intercostal 
space  between  the  situation  of  the  apex  and  the  base  of 
tiie  heart.  These  abnormal  impulses  are  felt  to  be  strong 
in  proportion  as  the  enlargement  is  due  to  hypertrophy, 


CONDITIONS    OP    HEART    IN    DISEASE.  193 

and  weak  in  proportion  as  dilatation  predominates.  En- 
largement seated  in  the  right  ventricle  causes  an  impulse 
in  the  e])igastrium  which  is  stronger  weak  in  proportion 
as  hypertrophy  ordilitation  predominates.  Cardiac  im- 
pulses are  felt  and  seen  in  abnormal  situations  when  the 
heart  is  removed  from  its  normal  situation  by  the  pres- 
sure of  an  aneurism,  or  other  tumor,  by  pleuritic  effu- 
sion, hydroperitoneum,  etc.  The  error  of  mistaking  for 
a  cardiac  impulse  the  pulsation  of  an  aneurismal  tumor 
is  to  be  avoided.  Another  error  is  to  be  avoided,  namely, 
mistaking  abnormal  impulses  due  to  the  heart  being  un- 
covered of  lung,  from  shrinking  of  the  latter  in  certain 
pulmonary  affections,  for  impulses  denoting  enlargement 
of  the  heart.  In  cases  of  enlargement  by  hypertrophy 
a  heaving  movement  of  the  whole  prsecordia  is  some- 
times felt  when  the  hand  is  applied  to  the  chest.  A 
violent  shock  is  sometimes  felt  by  the  hand  applied  to 
the  prsecordia,  but  without  a  sense  of  increased  mus- 
cular power,  in  cases  of  purely  functional  disorders  of 
the  heart. 

Valvular  .Lesions. — The  lesions  affecting  the  valves  of 
the  heart  are  of  a  varied  character,  for  an  account  of 
which  the  student  is  referred  to  treatises  on  cardiac  dis- 
eases, or  on  pathological  anatomy.  It  suffices  here  to 
consider  that,  with  reference  to  physical  signs  and  patho- 
logical effects  they  may  be  distributed  into  three  groups, 
as  follows:  1st,  lesions  which  diminish  more  or  less  the 
size  of  the  orifices,  or  obstructive  lesions;  2d,  lesions 
which  render  the  valves  more  or  less  incompetent  and 
permit  regurgitation,  or  regurgitative  lesions  ;  and  3d, 
lesions  which  roughen  the  surface  over  which  the  blood 
moves  without  occasioning  either  obstruction  or  regurgi- 
tation.    The  latter  may  be  distinguished  as  innocuous 


194  TUE    HEART. 

lesions,  giving  rise  to   no  pathological  effects  although 
represented  by  cardiac  murmurs. 

It  is  to  be  borne  in  mind  that  in  the  great  majority 
of  cases  valvular  lesions  are  seated  in  the  left  side  of 
the  heart,  that  is,  they  are  either  mitral  or  aortic.  Tri- 
cuspid and  pulmonic  lesions  are  comparatively  rare,  and 
they  are  generally  congenital.  Not  infrequently  mitral 
and  aortic  lesions  coexist,  and  there  may  be  coexisting 
lesions  at  all  the  orifices  of  the  heart. 

Valvular  lesions  are  represented  by  cardiac  murmurs. 
By  means  of  tlie  murmuj's  the  existence  of  lesions  is 
known,  their  situation  at  the  different  orifices  may  be 
ascertained,  and,  generally,  it  is  practicable  to  determine 
whether  they  occasion  obstruction  or  regurgitation,  or 
both.  These  several  points  of  inquiry  will  be  consid- 
ered presently  under  the  heading  Cardiac  i\Ji|irmurs,  and 
in  connection  with  the  lesions  of  the  different  valves  re- 
spectively in  the  next  chapter. 

Roughness  of  the  Pericardial  Surfaces. — In  place  of 
the  smoothness  of  the  pericardial  surfaces  in  health, 
which  permits  their  movements  upon  each  other  noise- 
lessly, the  presence  of  the  inflammatory  product  lymph, 
and,  in  some  rare  instances  morbid  growths,  occasion  an 
adventitious  sound  or  murmurs,  which  will  be  noticed 
in  connection  with  other  murmurs,  and  as  entering  into 
the  ])hysical  diagnosis  of  pericarditis. 

Liquid  icithin  the  Pericardial  Sac. — More  or  less 
liquid  transudes  into  the  pericardial  sac  in  cases  of 
general  dropsy  or  anasarca,  but  rarely  in  very  large 
quantity.  Liquid  effusion  occurs  in  acute  pericarditis, 
and  in  this  affection  the  sac  may  become  filled  with 
liquid.     In  some  cases  of  chronic  pericarditis  the  sac  is 


ABNORMAL    MODIFICATIONS    OF    SOUNDS.       195 

greatly  dilated  by  liquid,  the  quantity  amounting  to  four 
pounds,  or  even  more. 

When  the  pericardial  sac  is  filled  with  liquid,  without 
being  dilated,  it  forms,  virtually,  a  pyrlform  tumor 
within  the  chest,  the  base  of  which  is  at  the  sixth  or 
seventh  intercostal  space ;  the  apex  rises  nearly  to  the 
sternal  notch ;  the  left  lateral  border  is  considerably 
beyond  the  nipple,  and  the  right  lateral  border  is  more 
or  less  beyond  the  right  margin  of  the  prsecordia.  The 
anterior  portion  of  the  filled  pericardium  is  mostly  un- 
covered of  lung  and  in  contact  with  the  walls  of  the 
chest.  Within  this  area  there  is  either  notable  dulness 
or  flatness  on  percussion,  together  with  absence  of  respi- 
ratory murmur  and  of  vocal  resonance.  By  means  of 
these  signs,  the  boundaries  of  the  pyriform  tumor  may 
be  readily  delineated  on  the  surface  of  the  chest. 

When  the  pericardial  sac  is  partially  filled  with  liquid, 
the  same  signs  are  present,  but  within  an  area  of  less 
extent,  and  the  configuration  of  the  pyriform  tumor  is 
want  in  o;. 

In  cases  of  chronic  pericarditis  with  a  large  accumu- 
lation of  liquid,  the  pericardial  sac  is  dilated  so  that  Its 
lateral  boundaries  may  extend  nearly  to  the  axillary  and 
infra-axillary  regions.  Under  these  circumstances,  flat- 
ness on  percussion,  absence  of  respiratory  murmur  and 
of  vocal  resonance,  are  present  over  the  greater  part  of 
the  anterior  aspect  of  the  chest. 

Abnormal  Modification  of  the  Heart-sounds. 

In  order  to  appreciate  the  abnormal  modifications  of 
the  heart-sounds,  their  normal  characters  are  to  be  kept 
in  mind  (fic/e  page  185),  and  the  student  must  be  prac- 
tically familiar  with  them.  The  modifications  relate 
especially  to  the  intensity  and  quality  of  the  first  and  the 


196  THE    HEART. 

second  sound.  Either  of  the  two  sounds  may  be  sup- 
pressed . 

The  first  sound  has  all  its  normal  characters  intensified 
when  the  power  of  the  ventricular  systole  is  increased 
by  hypertrophy.  The  sound  is  louder  than  in  health  ; 
it  is  longer,  and  the  booming  quality  is  more  marked. 
If  obstructive  or  regurgitant  valvular  lesions  do  not  exist, 
the  second  sound  is  also  intensified,  without  change  in 
other  respects.  The  first  sound,  when  much  intensified, 
sometimes  has  a  ringing  tone  or  tinnitus.  This  is  also 
sometimes  observed  in  health  when  the  power  of  the 
heart's  action  from  any  cause  is  increased. 

In  some  cases  of  violent  palpitation  the  first  sound  is 
notably  intense,  but  short  and  valvular  in  quality.  I 
suppose  the  explanation  of  this  to  be  as  follows :  the  ven- 
tricles contract  with  a  kind  of  spasmodic  action  upon  a 
small  quantity  of  blood  ;  and,  under  these  circumstances, 
the  auriclo-ventricular  valves,  not  being  floated  out  as 
they  are  when  the  ventricles  are  well  filled,  expand  with 
force  in  the  ventricular  systole,  instead  of  being  merely 
made  tense  as  in  health.  Hence,  the  valvular  element  of 
the  first  sound  is  much  intensified,  while  those  characters 
of  the  first  sound  which  are  due  to  the  impulsion  of  the 
heart  against  the  walls  of  the  chest,  may  be  feeble  or 
wanting. 

Weakening  or  suppression  of  the  first  sound  over  the 
apex  is  an  effect  of  those  affections  of  the  heart  which 
diminish  the  power  of  the  ventricular  systole.  These 
affections  are  enlargement  from  dilatation,  atrophy,  fatty 
degeneration,  myocarditis,  obstruction  of  the  coronary 
arteries,  and  softening.  If  the  sound  be  notably  weak- 
ened, it  becomes  short  and  valvular  like  the  second 
sound.     These  changes  sliow  that  the  characters  depend- 


ABNORMAL    MODIFICATIONS    OF    SOUNDS.       197 

cnf/  on  the  element  of  impulsion  are  affected  more  than 
the  valvular  element.  Liquid  effusion  within  the  peri- 
cardium renders  the  first  sound  more  or  less  weak  and 
valvular,  the  characters  derived  from  impulsion  being 
under  these  circumstances  wanting.  Diminished  power 
of  the  heart's  action  from  other  than  cardiac  diseases,  in- 
volves weakness  of  both  the  heart-sounds,  but  more 
especially  of  the  first  sound. 

The  abnormal  modifications  of  the  second  sound,  which 
are  chiefly  of  interest  and  importance,  relate  to  the 
aortic  and  pulmonic  sound  considered  separately.  Bear- 
ins:  in  mind  the  mode  of  interroo-atino;  the  aortic  and  the 
pulmonic  orifice  with  reference  to  the  valvular  sound  de- 
rived from  each  independently  of  the  other  (vide  page 
188),  a  comparison  of  the  two  sounds  in  diseases  of  the 
heart  affords  often  useful  information.  Whenever,  from 
mitral  obstruction  or  regurgitant  lesions,  or  both  com- 
bined, the  blood  propelled  by  the  left  ventricle  into  the 
aorta  is  diminished,  the  recoil  of  the  arterial  coats,  after 
the  ventricular  systole,  is  lessened  ;  consequently,  the 
aortic  segments  expand  with  less  force,  and  the  valvular 
sound  is  weakened.  Diminished  intensity  of  the  aortic 
sound  thus  represents  an  abnormal  diminution  of  thequan- 
tity  of  blood  propelled  into  the  systemic  arteries  in  the 
systole  of  the  left  ventricle,  and  this  diminished  intensity 
is,  in  a  measure,  a  criterion  of  the  amount  of  mitral  ob- 
struction or  mitral  regurgitation,  or  both  combined.  In 
some  cases  of  extreme  obstruction  or  regurgitation,  the 
aortic  sound  is  completely  suppressed.  How  is  weaken- 
ing of  this  sound  to  be  determined  and  measured  ?  By 
comparison  with  the  })ulmonic  sound.  Now,  as  will 
presently  appear,  the  pulmonic  sound  is  apt  to  be  in- 
tensified when  the  aortic  sound  is  weakened.     Hence, 

17 


198  THE    HEART. 

the  former  is  not  an  accurate  standard  for  this  com- 
parison ;  but  it  suffices  for  an  approximation  to  accuracy. 
In  cases  of  hypertrophy  of  the  left  ventricle  without 
obstructive  or  regurgitant  valvular  lesions,  the  aortic 
sound  is  abnormally  intensified.  These  cases  occur 
chiefly  in  connection  with  fibroid  or  atrophic  lesions  of 
the  kidneys. 

A  simpler  cause  of  weakening  or  suppression  of  the 
aortic  sound,  is  damage  from  lesions  of  the  aortic  valve. 
In  proportion  as  the  function  of  this  valve  is  impaired 
by  lesions,  the  intensity  of  the  sound  is  diminished,  and 
if  the  function  of  the  valve  be  lost,  the  sound  is  wanting. 
In  these  cases,  the  pulmonic  sound  being  but  little  or 
not  at  all  affected,  it  is  an  accurate  standard  for  the 
comparison. 

The  pulmonic  sound  is  weakened  in  the  rare  instances 
of  lesions  affecting  the  pulmonic  valve.  This  sound  is 
oftener  intensified  than  weakened.  It  is  notably  inten- 
sified when  the  right  ventricle  is  hypertrophied,  and 
especially  when  this  hypertrophy  is  associated  with  dila- 
tation of  the  left  auricle  resulting  from  mitral  obstruc- 
tion or  regurgitation.  These  lesions  weakening,  as  has 
just  been  seen,  the  aortic  sound,  the  contrast  between 
the  aortic  and  the  pulmonic  sound  in  some  cases  of 
mitral  lesions  is  very  marked.  The  pulmonic  sound  is 
sometimes  loud  while  the  aortic  sound  is  suppressed. 

In  comparing  the  aortic  and  the  pulmonic  sound  in 
disease,  as  in  health,  it  is  to  be  assumed  that  the  anatom- 
ical relations  of  the  aortic  and  the  pulmonary  artery  to 
the  second  intercostal  space  on  either  side,  close  to  the 
sternum,  are  not  materially  altered,  and  that  the  lungs 
are  free  from  lesions  in  consequence  of  which  the  con- 
duction of  the  sound  on  either  side  is  abnormal. 


ABNORMAL    MODIFICATIONS    OF    SOUNDS.       199 

Keturnlng  to  the  first  sound  of  the  heart,  the  mitral 
and  the  tricuspid  part  of  the  valvular  element  of  this 
sound  may  be  studied  separately.  With  the  stethoscope 
applied  at  or  a  little  to  the  left  of  the  apex,  the  valvular 
element  of  the  first  sound,  which  is  heard,  is  derived 
chiefly  from  the  mitral  valve.  On  the  other  hand,  if 
the  stethoscope  be  applied  at  or  near  the  right  lower 
border  of  the  heart,  the  valvular  element  is  derived 
chiefly  from  the  tricuspid  valve.  Notable  weakness  or 
suppression  of  the  mitral  valvular  sound,  as  compared 
with  the  tricuspid,  represents  impairment  of  the  function 
of  the  mitral  valve,  and,  per  contra,  notable  weakness 
or  suppression  of  the  tricuspid  valvular  sound  denotes 
impairment  of  the  function  of  the  tricuspid  valve. 
Allowance  in  this  comparison  is  to  be  made  for  a  nor- 
mal disparity,  the  mitral  valvular  sound  being  louder 
than  the  tricuspid  in  health. 

RedupliGcdion  of  Heart-sounds. — The  sounds  of  the 
heart  are  said  to  be  reduplicated  wdien  either  the  first  or 
the  second  sound  is  repeated,  or  when  each  sound  occurs 
twice  before  the  long  pause  or  interval.  Considering 
the  heart-sounds  as  represented  by  the  whispered  words 
Lub-dup,  reduplication  of  the  first  sound  is  expressed 
by  Lublub-dup,  of  the  second  by  Lub-dupdup,  and  of 
both  sounds  by  Lublub-dupdup. 

Clinically,  reduplication  of  the  second  sound  is  much 
more  frequent  than  reduplication  of  either  the  first  sound, 
or  of  both  sounds.  Yet,  accepting  the  explanation  which 
seems  most  reasonable  of  this  anomaly,  both  sounds 
should  always  be  reduplicated,  that  is,  neither  should 
be  reduplicated  separately.  It  is  probable  that  both 
sounds  are  always  reduplicated,  but  the  reduplication  of 


200  THE    HEART. 

one  of  them  (generally  the  first  sound)  from  its  feeble- 
ness is  not  appreciable. 

There  is  a  form  of  disorder  which  maybe  confounded 
with  reduplication  of  both  sounds  of  the  heart.  In  this 
disorder,  with  every  alternate  revolution  of  the  heart, 
the  sounds  are  weak,  and  the  ventricular  systole  is  not 
represented  by  a  radial  pulse,  the  force  of  the  contraction 
of  the  ventricle  being  insufficient  to  cause  an  appreciable 
pulsation  in  the  remote  arteries;  hence,  the  heart-sounds 
occur  twice  for  each  pulse  at  the  wrist.  Under  these 
circumstances,  however,  the  carotid  pulse  may  generally, 
if  not  always,  be  felt  with  the  weak,  as  well  as  with  the 
stronger,  ventricular  contraction,  and  in  this  way  the 
error  of  confounding  the  disorder  with  reduplication 
may  be  avoided. 

The  explanation  of  reduplication  is,  that  instead  of  the 
two  ventricles  contracting  in  unison,  as  in  health,  one 
contracts  a  little  before  the  other.  This  explanation 
accounts  satisfactorily  for  the  anomaly. 

Reduplication  of  the  heart-sounds  may  occur  in  con- 
nection with  cardiac  lesions,  or  there  may  be  no  evidence 
of  any  organic  affection.  In  the  latter  case  the  anomaly 
falls  properly  among  the  varied  forms  of  functional  dis- 
order of  the  heart.  Whether,  or  not,  it  be  connected 
with  lesions,  it  has  no  important  pathological  significance. 
It  is  usually  of  temporary  duration. 

Cardiac  Murmurs. 

All  adventitious,  abnormal  sounds  which  are  added 
to  the  heart-sounds,  are  embraced  by  the  term  cardiac 
murmurs.  Let  it  be  borne  in  mind  that,  conventionally, 
the  murmurs  are  never  abnormal  modifications  of  the 
heart-sounds,  but  always  newly  produced  sounds,  and 


CARDIAC    MURMURS.  201 

they  always  represent  morbid  conditions  of  either  the 
heart  or  the  blood.  When  due  to  morbid  conditions  of 
the  blood,  they  are  called  inorganic,  anaemic,  hamic 
murmurs,  and  when  they  represent  valvular  lesions  or 
changes  within  the  heart,  they  are  distinguished  as  or- 
ganic murmurs. 

The  organic  murmurs  may  be  distributed  into  three 
groups  after  differences  in  quality,  namely;  1st,  soft, 
2d,  rough,  and  3d,  musical  murmurs.  The  soft  mur- 
murs resemble  the  sound  produced  by  air  from  the 
nozzle  of  a  pair  of  bellows,  and,  hence,  are  often  called 
bellows  murmurs.  Murmurs  are  said  to  be  rough  when 
their  qualities  may  be  expressed  by  such  terms  as  rasp- 
ing, grating,  creaking,  croaking,  etc.  They  are  called 
musical  when  the  sound  is  a  musical  note.  The  bellows 
murmurs  are  of  most  frequent  occurrence,  and  the  musi- 
cal are  much  more  rare  than  the  rough  murmurs.  The 
quality  of  a  murmur  does  not  in  general  invest  it  with 
any  special  pathological  or  diagnostic  significance.  The 
murmurs  vary  in  pitch,  being  either  relatively  high  or 
low.  The  variations  in  pitch  are  useful  in  aiding  to  dis- 
criminate different  coexisting  murmurs. 

This  account  of  organic  murmurs  applies  to  those  pro- 
duced at  the  orifices  or  within  the  cavities  of  the  heart. 
They  are  distinguished  as  endocardial  murmurs.  Ad- 
ventitious sounds,  are,  however,  produced  upon  the  ex- 
ternal surface  of  the  heart.  These  constitute  what  is 
called  exocardial,  pericardial,  or  friction  murmurs. 

Endocardial  murmurs  are  produced  by  blood-currents 
pursuing  either  a  normal  or  an  abnormal  direction. 
With  a  familiar  knowledge  of  these  currents,  and  of 
their  relations  with  the  heart-sounds,  the  several  endo- 
cardial murmurs  are  very  easily  understood,  as  regards 


202  THE    HEART. 

points  involved  in  their  differentiation  from  each  other. 
The  student  is,  therefore,  advised  first  to  become  ac- 
quainted with  the  blood-currents  in  health  and  in  dis- 
ease. Directing  the  attention  to  the  left  side  of  the  heart, 
there  are  two  normal  blood-currents,  namely,  the  current 
from  the  left  auricle  to  the  left  ventricle,  and  the  current 
from  the  left  ventricle  into  the  aorta.  These  may  be 
distino-uished  as  the  direct  currents.  The  first  is  the 
mitral  direct  current,  and  the  second  is  the  aortic  direct 
current.  Two  abnormal  currents  may  occur  in  the  left 
side  of  the  heart.  These  currents  can  only  take  place 
when  the  valves  are  rendered  incompetent  by  lesions. 
The  incompetency  of  the  valves  allows  of  regurgitation, 
and  these  abnormal  currents  may  be  distinguished  as 
the  regurgitant  currents.  One  of  these  is  a  current  back- 
ward from  the  left  ventricle  into  the  left  auricle,  owing 
to  incompetency  of  the  mitral  valve;  this  is  the  mitral 
regurgitant  current.  The  other  is  a  current  backwards 
from  the  aorta  into  the  left  ventricle,  arising  from  in- 
competency of  the  aortic  valve  ;  this  is  the  aortic  regur- 
gitant current. 

What  are  the  relations  of  these  four  currents  in  the 
left  side  of  the  heart  with  the  heart  sounds?  The  mi- 
tral direct  current  takes  place  when  the  auricles  contract. 
The  contraction  of  the  auricles  precedes  the  ventricular 
systole.  The  ventricular  systole  is  synchronous  with 
the  first  sound  of  the  heart.  The  mitral  direct  current, 
therefore,  takes  place  just  before  the  first  sound  of  the 
heart.  It  begins  after  the  second  sound,  and  continues 
until  it  is  suddenly  and  completely  arrested  by  the  con- 
traction of  the  ventricle.  It  is  obvious  that  the  current 
cannot  continue  during  the  ventricular  contraction,  that 
is,  when  the  first  sound  of  the  heart  is  produced.     The 


CARDIAC    MURMURS.  203 

mitral  regurgitant  current  is  caused  by  the  contraction 
of  the  ventricle;  the  current,  therefore,  must  take  phice 
with  the  first  sound  of  tlie  heart.  This  current  is  sys- 
tolic in  the  time  of  its  occurrence.  The  aortic  direct 
current,  being  caused  by  the  contraction  of  the  left  ven- 
tricle, takes  place  with  the  first  sound  of  the  heart.  It 
is,  therefore,  coincident  with  the  mitral  regurgitant  cur- 
rent. The  aortic  regurgitant  current  is  caused  by  the 
recoil  of  the  arterial  coats  upon  the  column  of  blood 
within  the  aorta  directly  after  the  ventricular  systole, 
and  as  this  recoil  causes  the  second  sound  of  the  heart, 
the  current  and  this  sound  must  be  coincident. 

Recapitulating  the  relations  of  the  four  currents  with 
the  heart-sounds,  the  aortic  direct  and  the  mitral  regur- 
gitant take  place  with  the  first  sound — they  are  systolic 
currents  ;  the  mitral  direct  current  precedes  the  first 
sound— it  is  presystolic;  and  the  aortic  regurgitant  cur- 
rent takes  place  with  the  second  sound — it  is  diastolic. 

Analogous  blood-currents  take  place  in  the  right  side 
of  the  heart,  and  have  corresponding  relations  with  the 
heart-sounds.  These  currents  are  the  tricuspid  direct, 
the  tricuspid  regurgitant,  the  pulmonic  direct,  and  the 
pulmonic  regurgitant.  The  pulmonic  regurgitant  is  ex- 
ceedingly rare  in  consequence  of  the  infrequency  of 
pulmonic  lesions;  but  the  tricuspid  regurgitant  is  not 
uncommon, and  probably  occurs  without  valvular  lesions 
or  enlargement  of  the  heart  when  the  right  ventricle  is 
distended  with  blood,  constituting  what  has  been  called 
the  "safety  valve  function  "  of  the  tricuspid  orifice. 

Organic  endocardial  murmurs  are  produced  by  the 
foregoing  direct  and  regurgitant  blood-currents,  and  they 
are  designated  by  the  same  names,  that  is,  they  are  either 
direct  or  regurgitant.     Thus,  there  are  produced  in  the 


204  THE    HEART. 

left  side  of  the  heart — the  side  in  which  valvular  lesions 
are  seated  in  the  great  majority  of  cases — a  mitral  direct 
murmur,  a  mitral  regurgitant  murmur,  an  aortic  direct 
murmur,  and  an  aortic  regurgitant  murmur.  In  the 
right  side  of  the  heart  there  may  be  produced  correspond- 
ing murmurs,  namely,  a  tricuspid  direct,  a  tricuspid  re- 
gurgitant, a  pulmonic  direct,  and  a  pulmonic  regurgi- 
tant. It  remains  to  point  out  the  means  of  diiferentia- 
ting  these  several  murmurs  aside  from  their  relations 
with  the  heart-sounds. 

Mitral  Dived  Murmur. — This  murmur  is  presystolic. 
It  begins  after  the  second  sound  and  ends  abruptly  with 
the  first  sound.  Almost  invariably,  this  murmur  is 
rough  in  quality ;  occasionally,  it  is  a  soft  bellows  murmur. 
When  rough,  it  is  often  quite  loud.  The  rough  qual- 
ity is  peculiar  ;  it  is  suggestive  of  vibration,  and  may  be 
imitated  by  causing  the  lips  or  the  tongue  to  vibrate 
with  the  breath  in  expiration.  I  state  the  mechanism 
of  this  murmur,  inasmuch  as  the  explanation  is  origi- 
nal with  me,  and  has  not  been  as  yet  generally  accepted. 
It  is  caused  by  the  vibrations  of  the  mitral  curtains,  and 
takes  place  especially  when  these  curtains  are  united  at 
their  sides,  leaving  a  narrow  orifice  through  which  the 
mitral  direct  current  of  blood  flows.  Throwing  the  lips 
into  vibration  with  the  breath,  re[)rcsents  not  only  the 
quality  of  the  murmur,  but  the  mode  of  its  production. 
The  physical  conditions  which  are  requisite  generally  for 
its  production  are  a  narrowed  mitral  orifice,  and  flac- 
cidity  of  the  mitral  curtains.  The  latter  of  these  condi- 
tions does  not  always  exist  in  cases  of  mitral  obstructive 
lesions,  and,  hence,  the  murmur  by  no  means  always  ac- 
companies these  lesions.  When  it  is  considered  how  loud 
a  blubbering  sound  may  be  produced  by  the  vibration 


CARDIAC    MURMURS.  205 

of  the  lips  with  a  feeble  current  of  air,  it  is  not  difficult 
to  uuderstand  that  an  intense  murmur  may  be  caused 
by  a  current  of  blood  propelled  by  the  comparatively 
weak  contraction  of  the  auricle. 

A  mitral  direct  murmur  may  be  produced  without 
mitral  lesions, the  murmur  having  the  same  rough  qual- 
ity as  when  lesions  exist,  and  being  also  quite  loud. 
This  statement,  based  on  clinical  proof,  was  made  by  me 
many  years  since,  together  with  the  explanation.  It 
occurs  when  there  are  aortic  lesions  which  permit  regur- 
gitation. Under  these  circumstances,  at  the  time  when 
the  auricular  contraction  takes  place,  the  left  ventricle 
is  already  tilled  with  blood,  the  mitral  curtains  are 
floated  out  so  as  to  be  in  contact  with  each  other,  and 
the  mitral  direct  current  passing  between  the  curtains 
throws  them  into  vibration  precisely  as  when  the  ori- 
fice is  narrowed.  Tlie  vibration  of  the  lips  when  lightly 
in  contact,  caused  by  the  ex})ired  breath,  illustrates  the 
manner  in  which  a  mitral  direct  murmur  takes  place 
without  mitral  lesions.  The  murmur  thus  occurring 
without  mitral  lesions  is  not  constant ;  it  is  now  pres- 
ent and  now  absent,  depending,  as  it  does,  on  the  quan- 
tity of  blood  within  the  left  ventricle  at  the  time  of  the 
contraction  of  the  auricle.  It  follows  from  what  has 
just  been  stated,  that  a  mitral  direct  murmur  is  not  al- 
ways a  sign  of  mitral  obstructive  lesions  when  there  is 
free  aortic  re2;ur2:itation. 

This  murmur  is  limited  to  a  circumscribed  space  around 
the  apex  of  the  heart.  However  loud  the  murmur  may 
be  in  this  situation,  it  is  lost  within  a  short  distance  from 
the  apex.^ 

^  Professor  Janeway  states  that  in  rare  instances  he  has  heard  this 
murmur  over  the  knver  part  of  the  scapula. 

18 


206  THE    HEART. 

A  mitral  direct  murmur  is  never  due  to  a  morbid  con- 
dition of  the  blood.  Although  it  occurs  without  mitral 
lesions,  yet,  inasmuch  as  its  occurrence  then  requires  the 
existence  of  aortic  regurgitant  lesions,  it  cannot  be  said 
to  be  an  inorganic  murmur. 

Mitral  Begurgitant  3Iurmur — Ilitral  Systolie  Non- 
regurgitant,  or  Intra-ventricular  Murmur. — The  mitral 
regurgitant  murmur,  synchronous  with  the  first  sound, 
that  is,  a  systolic  murmur,  may  be  soft,  rough,  or  musical 
in  quality,  its  intensity  and  pitch  being  variable.  Aside 
from  its  relation  with  the  first  sound  of  the  heart,  it  is 
distinguished  by  having  its  maximum  of  intensity  at  or 
near  the  situation  of  the  a})ex-beat.  It  may  be  limited 
to  a  circumscribed  area,  and  if  heard  at  a  distance  from 
the  apex  it  is  best  transmitted  laterally  around  the  left 
side  of  the  chest.  It  is  often  heard  on  the  posterior  as- 
pect of  the  chest  on  the  left  side  near  the  lower  angle  of 
the  scapula,  and  not  infrequently  in  the  corresponding 
situation  on  the  right  side. 

A  murmur  with  the  first  sound  heard  within  a  limited 
area  at  the  apex,  may  be  due  to  roughness  of  the  endo- 
cardial membrane  without  mitral  incompetency,  and, 
consequently,  without  a  mitral  regurgitant  current.  This 
is  a  mitral  systolic  non-regurgitant  murmur.  It  may, 
also,  be  called  an  intra-ventricular  murmur,  being  pro- 
duced, not  at  the  mitral  orifice,  but  within  the  ventricle. 
This  murmur  cannot  always  be  discriminated  from  a 
feeble  mitral  regurgitant  murmur.  If,  however,  a  mitral 
murmur  be  conducted  laterally  for  some  distance  to  the 
left  of  the  apex,  and  if  it  be  heard  on  the  back,  it  may 
be  considered  to  represent  mitral  regurgitation.  A  mitral 
systolic,  non-regurgitant,  or  intra-ventricular  murmur  is 
the  murmur  present  in  endocarditis.     It  may  be  caused 


CARDIAC    MURMURS.  207 

by  a  tendinous  cord  extending  from  the  inner  wall  on 
one  side  to  the  opposite  side  of  the  ventricular  cavity. 
This  occurs  as  a  congenital  anomaly.  Aneurism  of  the 
heart  may  be  so  situated  as  to  give  rise  to  a  murmur 
simulating  a  mitral  systolic  murmur.  Cardiac  aneurism, 
however,  is  exceedingly  rare.  Aneurism  of  the  thoracic 
aorta  may  cause  a  murmur  which,  transmitted  through 
the  heart,  simulates  a  mitral  systolic  murmur. 

The  impulse  of  the  apex  of  the  heart  against  the  ad- 
jacent portion  of  the  lung  sometimes  forces  the  air  from 
the  air-vesicles  sufficiently  to  give  rise  to  a  blowing 
sound  occurring  with  each  ventricular  systole.  This 
is  liable  to  be  confounded  with  an  endocardial  mur- 
mur. Produced  in  the  way  just  stated  it  may  be  heard 
only  during  the  act  of  inspiration,  and  especially  at  the 
end  of  this  act. 

A  mitral  systolic  murmur  is  rarely,  if  ever,  due  to  an 
abnormal  condition  of  the  blood,  without  any  anatomi- 
cal change  in  the  valve  or  endocardial  membrane.  Con- 
ditions of  the  blood,  however,  which  are  favorable  for 
the  production  of  inorganic  murmur  may  intensify  this 
murmur  as  well  as  any  of  the  organic  murmurs. 

Aortic  Direct  Murmur. — This  murmur,  like  the  mitral 
systolic  murmurs,  occurs  with  the  first  sound  of  the 
heart,  that  is,  it  is  systolic.  Of  the  organic  murmurs 
on  the  left  side  of  the  heart,  the  mitral  systolic  mur- 
murs and  the  aortic  direct  murmur,  are  synchronous, 
the  others  having  different  relations  with  the  heart- 
sounds.  The  aortic  direct  murmur  differs  from  the  mi- 
tral systolic  murmurs  in  having  its  maximum  of  inten- 
sity at  the  base  of  the  heart.  It  is  loudest  in  the  sec- 
ond intercostal  space  near  the  sternum.  As  a  rule,  it  is 
louder  in  this  intercostal  space  on  the  right  than  on  the 


208  THE    HEART. 

left  side ;  tliis  rule,  however,  has  frequent  exceptions. 
It  is  transmitted  better  and  further  upward  than  down- 
ward. It  is  always  heard  over  the  carotid  artery ;  and 
it  is  sometimes  louder  over  this  artery  than  at  the  base 
of  the  heart.  As  a  murmur  may  be  produced  within 
the  carotid  artery,  it  is  desirable  to  determine,  when  a 
systolic  murmur  is  heard  at  the  base,  whether  the  carotid 
murmur  is  a  transmitted  murmur  or  not.  This  point  is 
to  be  settled  by  comparing  the  murmur  over  the  carotid 
with  the  murmur  at  the  base,  as  regards  quality  and 
pitch.  If  the  quality  and  pitch  of  the  murmur  in  the 
two  situations  be  the  same,  it  is  fair  to  consider  the  mur- 
mur in  the  carotid  as  not  produced  within  the  artery, 
but  conducted  by  the  blood-current  from  the  aortic  ori- 
fice. 

An  aortic  direct  murmur  is  frequently  inorganic.  It 
is  to  be  considered  as  such  when  it  is  not  associated  with 
an  aortic  regurgitant  murmur ;  when  the  heart  is  not 
enlarged ;  when  anaemia  is  shown  by  the  presence  of 
murmurs  in  tlie  large  arteries ;  and  when  there  is  the 
venous  hum  in  the  neck — these  physical  evidences  of 
anaemia  being  associated,  generally,  not  invariably,  with 
pallor,  and  with  symptoms  pointing  to  impoverishment 
of  the  blood.  Moreover,  an  inorganic  murmur  is  very 
rarely  rough,  and  it  is  variable  in  its  occurrence,  being 
at  onetime  present  and  at  another  time  absent,  whereas, 
an  organic  murmur  is,  in  general,  constant.  Associated 
with  other  evidence  of  anaemia,  an  aortic  direct  murmur 
may,  nevertheless,  be  organic,  but,  under  the  differen- 
tiating circumstances  just  stated,  the  lesion  represented 
by  the  murmur,  if  the  murmur  be  organic,  must  be  in- 
nocuous, so  that  it  is  not  of  great  practical  importance  to 
determine  whether  the  murmur  be  or  be  not  inorganic. 


CARDIAC    MURMURS.  209 

Like  the  other  organic  murmurs,  an  aortic  direct  mur- 
mur varies  in  different  cases  in  its  intensity,  quality,  and 
pitch.  An  organic  aortic  direct  murmur,  per  se,  does 
not  denote  always  aortic  obstruction.  It  may  be  due 
simply  to  roughness  of  the  membrane  at  or  above  the 
aortic  orifice. 

Aortic  Regwgitant  Murmur — Aortic  Diastolic  Non- 
regurgitant  Murmur, — An  aortic  regurgitant  murmur 
occurs  with  the  second  sound  of  the  heart,  and  it  is  the 
only  one  of  the  organic  murmurs  produced  in  the  left 
side  of  the  heart  which  has  this  relation  with  the  heart- 
sounds.  It  is,  therefore,  readily  enough  discriminated 
from  the  other  murmurs.  It  is  almost  always  heard  at 
the  base  of  the  heart,  but,  in  some  instances,  when  not 
appreciable  at  the  base,  it  is  heard  a  little  below  the 
base,  namely,  near  the  sternum  on  the  left  side  on  a 
level  with  the  fourth  costal  cartilage.  In  the  latter  sit- 
uation it  has  generally  its  maximum  of  intensity.  It  is 
transmitted  best  in  a  downward  direction,  being  often 
heard  at  the  apex,  and  sometimes  considerably  below 
this  point.  It  is  never  inorganic.  It  is  usually  not  in- 
tense, low  in  pitch,  and  soft;  but  it  may  be  loud,  high, 
rough,  or  musical. 

A  short  murmur  is  sometimes  produced  by  the  retro- 
grade movement  of  the  blood-current  within  the  aorta, 
the  aortic  valve  being  sufficient,  and  regurgitation  not, 
therefore,  taking  place.  This  murmur  is  due  to  rough- 
ening of  the  lining  membrane  of  the  aorta  by  atheroma  or 
calcareous  deposit,  and  it  is  always  preceded  by  an  aortic 
direct  murmur.  It  occurs  directly  after  the  systole,  and 
ends  with  the  second  sound.  Although  of  such  brief 
duration,  it  is  distinctly  recognizable  and  distinguished 
from  the  preceding  aortic  direct  murmur.     I  have  long 


210  THE    HEART. 

been  accustomed  to  demonstrate  this  murmur  in  private 
teaching,  and  have  called  it  an  aortic  diastolic  non-re- 
gurgitant  murmur.  It  cannot  be  said  to  have  practical 
importance,  inasmuch  as  the  lesion  giving  rise  to  it  is 
represented  by  the  aortic  direct  murmur  which  pre- 
cedes it. 

Coexisting  Endocardial  Murmurs. — The  murmurs 
referable  to  the  left  side  of  the  heart,  which  have  been 
considered,  are  often  found  in  combination  ;  two  or  three 
may  coexist,  or  all  of  them  may  be  present.  Moreover, 
with  more  or  less  of  these  murmurs  may  be  associated 
murmurs  referable  to  the  right  side  of  the  heart. 
Havins:  become  familiar  with  their  relations  with  the 
heart-sounds,  and  other  points  involved  in  their  differ- 
entiation, it  is  not  difficult  to  recognize  them  in  combi- 
nation. The  mitral  murmurs  are  not  infrequently  asso- 
ciated. The  mitral  direct,  being  presystolic,  ends  with 
the  first  sound,  and  the  mitral  systolic  or  regurgitant 
begins  with  this  sound ;  the  first  sound,  as  it  w^ere, 
divides  these  two  murmurs.  The  murmurs  almost  in- 
variably difiPer  from  each  other  in  pitch  and  quality. 
The  presence  of  both,  in  fact,  assists,  rather  than  ob- 
structs, the  recognition  of  each.  The  aortic  direct  and 
the  aortic  regurgitant  murmur,  also,  are  often  associated. 
A  murmur  then  accompanies  the  first  and  the  second 
sound  of  the  heart ;  the  two  murmurs  follow  in  the  same 
rhythmical  order  as  the  heart-sounds.  These  murmurs, 
when  associated,  can  only  be  confounded  with  pericar- 
dial friction-sounds. 

The  combination  of  the  aortic  direct  and  the  mitral 
systolic  murmur  alone  offers  any  difficulty.  These  two 
murmurs  have  the  same  relation  with  the  heart-sounds; 
they  are  both  systolic.     How  is  it  to  be  determined, 


CARDIAC    MURMURS.  211 

wlieii  a  systolic  murmur  is  heard  both  at  the  base  and 
apex,  that  either  a  mitral  murmur  is  transmitted  to  the 
base,  or  an  aortic  murmur  is  transmitted  to  the  apex  ; 
in  other  words,  how  is  it  to  be  decided  whether  two 
murmurs  are  present  or  only  one  murmur?  If  these 
two  murmurs  coexist,  generally  the  circumstances  which 
distinguish  each  separately  can  be  ascertained.  Thus, 
the  aortic  murmur  is  transmitted  into  the  carotid  arterv, 
and  the  presence  of  that  murmur  is  then  established  ; 
the  mitral  regurgitant  murmur  is  often  transmitted 
laterally  around  the  chest  or  heard  at  the  lower  antrle  of 
the  scapula,  and  then  the  presence  of  that  murmur  is 
established.  But  there  are  additional  points,  namely, 
the  murmur  at  the  base  and  that  at  the  apex  generally 
differ  sufficiently  in  pitch  or  quality  to  render  it  evident 
that  there  are  two  murmurs;  and  generally  at  a  situ- 
ation in  the  prsecordia  between  the  base  and  apex,  both 
murmurs  may  be  either  lost  or  become  notably  w^eakened. 
Attention  to  these  points  in  most  instances  divests  the 
problem  of  difficulty. 

Mitral  and  aortic  lesions  are  often  of  a  character  to 
give  rise  to  only  one  murmur  at  either  of  these  orifices. 
A  mitral  direct  murmur  not  infrequently  is  present  with- 
out the  mitral  regurgitant,  and  the  reverse  of  this  is  fre- 
quent. So,  either  an  aortic  direct  or  an  aortic  regurgi- 
tant murmur  may  exist  without  the  other. 

Tricuspid  Direct  Murmur. — The  lesions  which  are 
requisite  for  this  murmur  very  rarely  occur  at  the  tri- 
cuspid orifice  ;  hence,  this  murmur  is  exceedinor:ly  rare. 
It  is  to  be  distinguished  from  the  mitral  direct  murmur 
by  its  localization  being,  not  at  the  apex,  but  at  the  right 
border  of  the  heart.     The  mitral  direct  and  the  tricuspid 


212  THE    HEART. 

direct  murmur  may  coexist;  an  instance  of  this  kind 
has  fallen  under  ray  observation.  In  that  instance  a 
pre-systolic  murmur,  Avith  the  characteristic  blubbering 
quality,  was  heard  both  at  the  apex  and  at  the  right  side 
of  the  heart. 

Tricuspid  JRegw-gitant  Murmui\ — This  murmur  is  not 
of  very  infrequent  occurrence.  Tricuspid  regurgitation 
occurs  often  when  the  right  ventricle  is  considerably  di- 
lated, without  the  existence  of  lesions  of  the  valve.  A 
tricuspid  regurgitation  current,  however,  does  not  inva- 
riably give  rise  to  an  appreciable  murmur.  This  fact  is 
shown  by  the  occurrence  of  a  venous  pulse  in  the  neck, 
due  to  tricuspid  regurgitation,  when  no  murmur  can  be 
heard. 

The  tricuspid  regurgitant  murmur,  of  course,  occurs 
with  the  first  sound,  being  systolic  like  the  mitral  re- 
gurgitant murmur,  and  the  latter  generally  coexists. 
It  is  distinguished  from  the  mitral  regurgitant  by  its 
localization  at  the  right  inferior  margin  of  the  heart,  and 
its  transmission  to  the  right  rather  than  to  the  left.  The 
coexistence  of  the  mitral  and  the  tricuspid  regurgitant 
murmur  is  determined  by  the  differences  in  pitch  and 
quality  between  a  systolic  murmur  at  the  apex  and  at 
the  right  margin  of  the  heart.  A  venous  pulse,  syn- 
chronous with  the  first  sound  of  the  heart,  points  to  tri- 
cuspid regurgitation,  and,  although  sometimes  present 
without  a  tricuspid  regurgitant  murmur,  when  present 
it  is  corroborative  evidence  of  the  latter. 

Pulmonic  Direct  Murmur. — A  pulmonic  direct  mur- 
mur, if  organic,  is  generally  connected  with  congenital 
lesions.  The  ])ulmonic  direct  and  the  aoi'tic  direct  cur- 
rent of  blood  taking  place  at  the  same  instant,  the  mur- 


CARDIAC    MURMURS.  213 

nuirs  representing  botli,  are,  of  course,  systolic.  How  is 
the  pulmonic  to  be  distinguished  from  the  aortic  direct 
murmur?  The  pulmonic  murmur  is  heard  in  the  left 
second  intercostal  space  close  to  tlie  sternum  ;  but  this  is 
not  very  distinctive,  inasmuch  as,  not  infrequently,  the 
aortic  murmur  is  loudest  in  that  situation.  The  essen- 
tial point  of  distinction  is  this:  the  pulmonic  direct 
murmur  is  not  transmitted  into  the  carotid  artery, 
whereas,  the  aortic  direct  murmur  is  always  thus  trans- 
mitted. If  an  aortic  direct  and  a  pulmonic  direct  mur- 
mur coexist,  both  being  organic,  the  combination  is  to 
be  ascertained  by  finding  that  the  murmur  in  the  second 
intercostal  space  on  the  right  side  differs  from  that  on 
the  left  side  in  pitch  or  quality  sufficiently  to  show  the 
presence  of  these  murmurs,  the  one  on  the  right  side  be- 
ing transmitted  to  the  carotid  artery. 

An  inorganic  pulmonic  direct  murmur  is  of  frequent 
occurrence.  It  is  generally  associated  with  an  inorganic 
aortic  direct  murmur,  the  presence  of  the  two  murmurs 
being  evidenced  by  a  difference  in  pitch. 

Pulmonic  Regurgitant  Murmm\ — This  murmur  must 
be  exceedingly  rare.  It  occurs,  of  course,  like  the  aortic 
regurgitant,  with  the  second  sound.  Its  presence  can 
only  be  determined  when  other  signs  go  to  show  the 
existence  of  pulmonic  and  the  absence  of  aortic  lesions. 
This  murmur,  as  well  as  the  aortic  regurgitant,  can 
never  be  inorganic,  its  presence  being  proof  of  a  re- 
gurgitant current  of  blood  from  incompetency  of  the 
pulmonic  valve. 

Facts  of  practical  importance  in  relation  to  the  endo- 
cardial murmurs,  are  embraced  in  the  following  state- 
ments : 


214  THE    HEART. 

The  question  as  to  a  murmur  being  organic  or  inor- 
ganic, relates  cliiefly,  if  not  entirely,  to  the  aortic  direct 
and  the  pulmonic  direct  murmur,  other  murmurs  being 
almost  invariably,  if  not  invariably,  organic. 

Associated  signs  and  symptoms  generally  warrant  a 
definite  conclusion  whether  an  aortic  direct  or  a  pul- 
monic direct  murmur  be,  or  be  not,  organic,  and  under 
the  circumstances  which  render  it  difficult  to  decide  this 
question  positively,  a  positive  decision  is  not  of  much 
immediate  practical  consequence. 

Valvular  lesions,  whether  obstructive,  regurgitant,  or 
innocuous,  are  so  uniformly  represented  by  murmur, 
that,  as  a  rule,  absence  of  lesions  may  be  predicated  on 
the  absence  of  murmur. 

With  a  practical  knowledge  of  the  different  organic 
murmurs,  the  situation  of  lesions  at  either  of  the  orifices 
of  the  heart,  or  their  existence  at  two  or  more  of  these 
orifices,  may  be  demonstratively  determined. 

By  means  of  the  murmurs,  with  other  signs,  it  may  be 
determined  demonstratively  whether  the  lesions  involve 
obstruction  or  regurgitation,  or  both,  or,  on  the  other 
hand,  that  they  are,  as  regards  immediate  pathological 
effects,  innocuous. 

The  murmurs  do  not  afford  definite  information  as  to 
the  amount  of  obstruction  or  regurgitation,  in  other 
words  as  to  the  pathological  importance  or  gravity  of 
lesions  when  they  are  not  innocuous.  No  positive  con- 
clusions on  this  point  of  view  are  to  be  drawn  from  the 
intensity  of  murmurs,  their  pitch,  or  their  quality.  As 
a  rule,  murmurs  which  are  weak,  more  than  those  which 
are  loud,  represent  grave  lesions. 

Pericardial  or  Friction  Murmur. — A  pericardial  or 
friction  murmur  is  produced  by  the  rubbing  together  of 


CARDIAC    MURMURS.  215 

the  surfaces  of  the  pericardium  in  the  systolic  and  dias- 
tolic movements  of  the  heart.  In  the  vast  majority  of 
the  cases  in  which  this  murmur  occurs,  it  denotes  either 
the  presence  of  recent  lympli  which  renders  the  surfaces 
more  or  less  adhesive,  or  roughening  from  lymph  which 
has  become  dense  and  adherent;  its  diagnostic  signifi- 
cance, therefore,  relates  almost  exclusively  to  pericar- 
ditis. In  this  relation  it  is  of  great  practical  importance. 
This  murmur  is  to  be  discriminated  from  the  endocar- 
dial murmurs.  The  points  involved  in  the  discrimination 
are  as  follows:  The  murmur  is  double,  that  is,  a  mur- 
mur accompanies  both  the  ventricular  systole  and  diastole. 
It  can,  therefore,  only  be  confounded  with  an  aortic  di- 
rect and  an  aortic  resfurp-itant  murmur  in  combination. 
The  quality  of  the  murmur  is  suggestive  of  rubbing  or 
friction.  It  is  sometimes  a  feeble,  grazing  sound;  in 
other  instances  it  is  loud  and  rough.  When  rough,  the 
quality  is  expressed  by  such  terms  as  rasping,  grating, 
creaking,  etc.  Although  accompanying  both  sounds  of 
the  heart,  it  has  not  that  uniform,  fixed  relation  to  these 
sounds  which  characterizes  the  aortic  direct  and  the 
aortic  regurgitant  murmur;  it  is  not  in  definite  accord 
with  the  heart-sounds.  Moreover,  in  intensity  it  varies 
with  the  successive  movements  of  the  heart,  being  louder 
with  some  revolutions  than  with  others,  in  this  regard 
differing  notably  from  the  endocardial  murmurs.  It  is 
not  heard  without  the  prsecordia,  as  a  rule,  and  is  often 
limited  to  a  part  of  the  prttcordial  region,  whereas,  cer- 
tain of  the  endocardial  murmurs,  namely,  the  mitral  re- 
gurgitant and  the  aortic  direct,  are  often  heard  at  a 
considerable  distance  from  the  heart.  Firm  pressure 
with  the  stethoscope  and  often  a  forced  expiration  in- 
tensify the  murmur.     Its  source  seems  very  near  the 


21G  THE    HEART. 

surface  of  the  chest.  In  this  respect  it  differs  notably 
from  endocardial  murmurs,  the  latter  appearing  to  come 
from  a  certain  distance  within  the  chest.  This  point  of 
distinction  is  very  appreciable,  especially  if,  as  often 
happens,  a  friction  murmur  be  associated  with  an  endo- 
cardial murmur. 


ENLARGEMENT    OF    THE    HEART.  217 


CHAPTER   VIII. 

THE    PHYSICAL    DIAGNOSIS    OF    DISEASES    OF    THE 
HEAKT  AND   OF   THORACIC  ANEURISM. 

Enlargement  of  the  heart  by  hypertrophy  and  dilatation — Valvular 
lesions,  mitral,  aortic,  tricuspid,  and  pulmonic — Fatly  degeneration 
and  softening  of  the  heart — Endocarditis — Pericarditis — Functional 
disorders — Thoracic  aneurism. 

The  morbid  physical  conditions  incident  to  the  different 
diseases  of  the  heart,  and  the  signs  representing  these 
conditions,  have  been  considered  in  the  preceding  chapter. 
The  diseases  are  now  to  be  considered  with  reference  to 
the  assemblage  of  signs  on  which  the  physical  diagnosis 
of  each  is  to  be  based.  Most  of  the  diseases  of  the  heart 
may  be  diagnosticated  by  means  of  physical  signs.  A 
few  cardiac  lesions  do  not  admit  of  a  physical  diagnosis, 
and  they  do  not,  therefore,  claim  consideration  in  this 
w^ork.  The  following  are  the  affections  which  will  form 
separate  headino|;s  in  this  chapter :  Enlargement  of  the 
Heart  by  Hypertrophy  and  by  Dilatation,  Valvular 
Lesions,  Fatty  Degeneration  and  Softening  of  the  Heart, 
Endocarditis,  Pericarditis,  and  Functional  Disorders. 
Having  considered  these  affections,  the  physical  diag- 
nosis of  thoracic  aneurism  will  be  the  concluding  topic. 

Enlargement  of  the  Heart  by  Hypertrophy  and  by 
Dilatation. — Physical  exploration  to  determine  the  size 
of  the  heart  has  three  objects,  namely  to  determine, 
first,  that  the  size  of  the  heart  is  normal ;  second,  that 
the  heart  is  enlarged  ;  and  third,  the  degree  of  enlarge- 


218  DISEASES    OF    THE    HEART. 

meiit.     Tliese  objects  are  attainable  by  means  of  percus- 
sion and  auscultation. 

The  heart  is  of  normal  size  when  the  apex -beat  is  in 
its  normal  situation,  that  is,  in  the  fifth  intercostal  space, 
a  little  within  a  vertical  line  passing  through  the  nipple 
(the  linea  mammillaris);  when  the  superficial  cardiac 
space  is  not  enlarged,  as  shown  by  percussion  and  by  aus- 
cultation of  the  voice  {vide  page  183)  and  when  percus- 
sion shows  the  lateral  borders  of  the  heart  to  be  situated 
normally,  namely,  on  the  left  side  a  little  within  the  line 
of  the  nipple,  and  on  the  right  side  of  a  finger's  breadth 
to  the  right  of  the  right  margin  of  the  sternum.  These 
points  of  evidence  warrant  a  positive  conclusion  that  the 
heart  is  not  enlarged. 

The  fact  of  an  enlargement  and  its  degree  are  deter- 
minable by  an  abnormal  situation  of  the  apex,  together 
with  an  increase  of  the  superficial  cardiac  space  and  ex- 
tension of  the  lateral  boundaries  of  the  deep  cardiac  space 
especially  on  the  left  side. 

In  cases  of  slight  or  very  moderate  enlargement,  the 
apex  is  situated  a  little  without  the  linea  mammillaris, 
but  not  below  the  fifth  intercostal  space.  A  somewhat 
greater  enlargement  lowers  the  apex  to  the  sixth  inter- 
costal space,  and  removes  it  further  without  the  line  of 
the  nipple.  In  greater  degrees  of  enlargement  the  apex 
is  lowered  to  the  seventh,  eighth,  or  ninth  intercostal 
space,  and  generally  further  removed  to  the  left.  The 
lowering  of  the  apex  and  the  removal  to  the  left,  are  not 
uniformly  proportionate  to  each  other.  As  a  rule,  if  the 
right  side  of  the  heart  be  more  enlarged  than  the  left,  the 
apex  is  removed  without  the  liuea  mammillaris  further 
than  when  the  enlargement  of  the  left  side  of  the  heart 
predominates,  and  when  the  latter  is  the  case,  the  apex 


ENLARGEMENT    OF    THE    HEART.  219 

is  lowered  out  of  proportion  to  its  removal  without  that 
line.  The  relatively  abnormal  situation  downward  and 
to  the  left,  thus,  is  evidence  of  the  enlargement  predomi- 
nating in  either  the  right  or  the  left  side  of  the  heart. 
Generally  the  situation  of  the  apex  is  apparent  to  the 
touch  and  frequently  to  the  eye.  In  some  instances, 
however,  the  impulse  can  neither  be  seen  nor  felt.  How 
is  its  S-ituation  to  be  then  ascertained?  Auscultation 
furnishes  a  ready  and  reliable  mode  of  determining  this 
point.  The  situation  in  which  the  first  sound  of  the 
heart  has  its  maximum  of  intensity,  as  ascertained  by 
means  of  the  stethoscope,  corresponds  to  the  situation  of 
the  apex.  This  is  hardly  less  definite  than  the  presence 
of  an  aj)preciable  impulse. 

In  determining  the  fact  of  enlargement  and  its  degree 
by  the  abnormal  situation  of  the  apex,  causes  of  the  lat- 
ter which  are  extrinsic  to  the  heart  are  to  be  eliminated. 
The  apex  is  removed  to  the  left  of  its  normal  situation 
by  enlargement  of  the  left  lobe  of  the  liver,  abdominal 
tumors,  hydroperitoneum,  the  pregnant  uterus,  and  gas- 
tric tympanites.  These  extrinsic  conditions  are  to  be 
excluded  or  due  allowance  made  for  them.  In  some 
cases  in  which  one  or  more  of  these  extrinsic  causes  of 
displacement  may  exist,  the  apex  is  carried  into  the  ax- 
illary region.  It  is  to  be  borne  in  mind  that  these  causes 
of  displacement  may  exist  when  there  is  more  or  less  en- 
largement of  the  heart.  All  these  causes,  while  they 
displace  the  apex  to  the  left,  do  not  lower,  but  tend  to 
raise  it  above,  its  normal  situation.  On  the  other  hand, 
an  aneurismal  or  other  tumor,  situated  above  the  heart, 
may  press  downward  the  organ,  and  in  this  way  the 
apex  is  more  or  less  lowered.^ 

^  Professor  Janeway  states  tl)at  he  lias  known  tlie  apex  lowered 
by  an  unusually  long  first  portion  of  the  aortic  arch. 


220  DISEASES    OF    THE    HEART. 

The  superficial  cardiac  sj3ace  is  increased  in  proportion 
as  tiie  heart  is  enlarged.  The  extent  of  this  increase  is 
easily  determined  by  percussion  and  auscultation.  Within 
this  space  there  is  notable  dulness  on  percussion.  The 
degree  of  dulness  is  greater  than  within  the  superficial 
cardiac  space  in  health,  and  this  degree  of  dulness  is  pro- 
portionate to  the  greater  area  in  which  the  heart  is  un- 
covered of  lung.  It  is  easy  to  delineate  by  percussion 
on  the  chest  the  boundary  of  the  anterior  border  of  the 
upper  lobe  of  the  left  lung,  in  other  words,  of  the  oblique 
line  which  is  the  hypothenuse  of  the  right-angled  tri- 
angle representing  the  superficial  cardiac  space  in  health 
and  in  disease.  The  area  of  the  superficial  cardiac  space 
is  also  not  less  readily  and  precisely  ascertained  by  auscul- 
tation of  the  voice;  the  limits  of  the  lung  within  the 
praecordia  are  denoted  by  an  abrupt  cessation  or  notable 
diminution  of  the  vocal  resonance.  In  women,  with 
large  mammae,  auscultation  is  more  available  for  this 
object  than  percussion.  The  extent  to  which  the  super- 
ficial cardiac  space  is  enlarged  is  a  good  criterion  of  the 
degree  of  the  enlargement  of  the  heart. 

In  proportion  as  the  heart  is  enlarged,  the  situation 
of  the  left  border  is  without  the  linea  mammillaris.  Its 
situation  is  determined  by  percussion.  Dulness,  although 
not  great,  is  sufficiently  distinct  within  the  deep  cardiac 
space,  and  the  line  which  denotes  the  left  border  of  the 
heart  is  easily  delineated  on  the  chest.  This  statement 
holds  true  with  respect  to  the  right  border  of  the  heart ; 
but  this  border,  even  when  the  enlargement  of  the  heart 
is  great,  is  removed  comj)aratively  little  to  the  right  of 
its  normal  situation.  By  means  of  percussion  the  bound- 
aries of  the  pr?ecordia  as  enlarged  by  the  increased  size 
of  the  heart  may  be  determined  and  measured.  In 
making  this  statement,  it  is  assumed  that  the  lungs  are 


ENLARGEMENT    OF    THE    HEART.  221 

not  diseased,  and  that  the  chest  is  not  deformed.  Shrink- 
age of  the  upper  lobe  of  the  left  lung  may  enlarge  the 
superficial  cardiac  space,  and  cause  displacement  of  the 
heart.  The  latter  is  an  effect  of  the  presence  of  pleu- 
ritic effusion,  and  it  may  follow  its  removal.  In  cases 
of  deformity  from  spinal  curvature,  to  determine  the  fact 
of  enlargement  of  the  heart,  or  its  degree,  is  not  always 
an  easy  problem. 

There  is  a  liability  to  error  in  localizing  the  apex  in 
some  cases  of  enlargement.  Owing  to  the  blunted  form 
of  the  apex,  especially  when  the  enlargement  is  chiefly  of 
the  right  side  of  the  heart,  the  apex-beat  may  be  feeble. 
It  is  liable  to  be  overlooked,  and  a  stronger  impulse  in 
the  intercostal  space  above  the  apex,  mistaken  for  the 
apex-beat.  Of  course,  the  lowest  impulse  is  the  apex- 
beat.  Careful  palpation,  and  finding  by  auscultation 
the  spot  where  the  first  sound  has  its  maximum  of  inten- 
sity, will  prevent  this  error. 

Enlarorement  of  the  heart,  and  the  de2:ree  of  enlarfje- 
ment  having  been  ascertained,  it  is  to  be  determined 
whether  hypertrophy  or  dilatation  predominate.  If  the 
enlargement  be  slight  or  moderate,  it  may  be  a  question 
whether  hypertrophy  or  dilatation  exist  alone.  As  a 
rule,  if  either  of  these  two  forms  of  enlargement  exist 
without  the  other,  it  is  hypertrophy,  for,  with  rare  ex- 
ceptions, hypertrophy  precedes  dilatation.  If  the  en- 
largement be  very  great,  as  a  rule,  dilatation  predomi- 
nates, for  the  capability  of  hypertrophic  increase  of  size 
has  its  limit,  and  an  increase  of  size  beyond  this  limit  must 
be  due  to  dilatation.  The  signs,  denoting  on  the  one 
hand  hypertroi)hy,  and  on  the  other  hand  dilatation,  re- 
late to  the  impulses  of  the  heart  and  to  the  heart-sounds. 

19 


222  DISEASES    OF    THE    HEART. 

With  a  moderate  enlargement,  hypertrophy  is  to  be 
inferred  from  an  abnormal  force  of  the  apex-beat,  and 
an  intensification  of  the  characters  of  the  first  sound  over 
the  apex.  With  a  considerable  or  great  enlargement,  if 
hypertrophy  predominate,  the  apex- beat  may  be  abnor- 
mally strong  and  prolonged,  but,  as  already  stated,  owing 
to  its  blunted  form,  the  beat  is  sometimes  weak  and 
scarcely  appreciable.  The  increased  power  of  the  ven- 
tricular contractions,  representing  the  hypertrophy,  is 
then  to  be  determined  by  impulses  in  the  intercostal 
spaces  above  the  apex.  These  impulses  are  sometimes 
present  in  each  intercostal  space  between  the  apex  and 
the  base,  and  they  are  abnormally  strong  in  proportion 
as  hypertrophy  predominates.  Still  more  marked  evi- 
dence of  hypertrophy  is  sometimes  obtained  when  the 
hand  is  placed  over  the  prsecordia  ;  a  powerful  heaving 
movement  is  felt.  The  increased  power  of  the  ventricu- 
lar contractions  may,  in  some  cases,  be  in  this  way  ap- 
preciated somewhat,  as  if  the  heart  were  held  in  the 
hand.  In  cases  of  considerable  or  great  enlargement, 
the  intensity  of  the  first  sound  over  the  apex  is  more  or 
less  increased  ;  it  is  prolonged,  and  its  booming  quality 
is  more  marked  than  in  health.  Not  infrequently  it  is 
accompanied  by  a  metallic  ringing  sound,  or  tinnitus. 

Moderate  enlargement  by  dilatation  is  characterized 
by  abnormal  weakness  of  the  apex-beat,  and  of  the  first 
sound  over  the  apex.  Cases,  however,  of  simple  dilata- 
tion are  rare.  If  the  enlargement  be  considerable  or 
great,  and  dilatation  predominate,  all  the  impulses  are 
weak,  as  compared  with  the  cases  in  which  hypertrophy 
predominates,  and  tiie  first  sound  over  the  apex  is  more 
or  less  divested  of  the  characters  derived  from  impulsion  ; 
that  is,  the  sound  is  feeble,  short,  and  valvular.     These 


VALVULAR    LESIONS.  223 

points  of  distinction  are  marked  in  proportion  as  dilata- 
tion predominates. 

In  the  great  majority  of  the  cases  of  enlargement  of 
the  heart,  valvular  lesions  coexist.  These  coexisting 
valvular  lesions  are  represented  by  endocardial  murmurs, 
and  they  are  excluded  by  the  absence  of  the  latter.  In 
most  of  the  cases  in  which  enlargement  exists  without 
valvular  lesions,  it  is  associated  with  either  pulmonary 
emphysema  or  chronic  Bright's  disease. 

Valvular  Lesions. 

The  physical  diagnosis  of  valvular  lesions  embraces 
their  localization  at  the  different  orifices  within  the 
heart,  and  the  determination  of  their  character  as  giving 
rise  to  obstruction  and  regurgitation,  or  of  their  innocu- 
ousness  in  these  respects.  These  objects  of  diagnosis 
involve  the  endocardial  murmurs,  and  the  abnormal 
modifications  of  the  heart-sounds  which  were  considered 
in  the  preceding  chapter.  Lesions  at  the  different  ori- 
fices, namely,  the  mitral,  aortic,  tricuspid,  and  pulmonic, 
will  be  considered  separately. 

Mitral  Lesions. — The  lesions  at  the  mitral  orifice  are 
represented  by  the  mitral  murmurs — the  mitral  direct 
murmur,  the  mitral  regurgitant,  and  the  mitral  systolic 
non-regurgitant  or  intra-ventricular  murmur.  Mitral 
obstructive  lesions  exist  whenever  the  mitral  direct  mur- 
mur is  present,  with  an  exception  already  stated  and 
explained  {vide  p.  205),  namely,  this  murmur  is  present 
in  some  cases  in  which  the  mitral  valve  is  intact,  aortic 
lesions,  giving  rise  to  free  regurgitation,  existing  in 
these  cases.  These  exceptional  instances  are  rare,  and  I  am 
not  aware  that  any  have  been  reported  except  by  m^'self. 


224  DISEASES    OF    THE    HEART. 

Mitral  regurgitant  lesions  exist  whenever  a  mitral 
murmur  which  is  truly  regurgitant  is  present.  A  sys- 
tolic murmur  having  its  maxim  of  intensity  at  or  near 
the  apex,  transmitted  laterally  for  a  certain  distance 
beyond  the  apex  on  the  left  side  of  the  chest,  and  heard 
on  the  back  near  the  lower  angle  of  the  scapula,  denotes 
a  regurgitant  current ;  but  a  systolic  murmur  limited  to 
a  small  area  around  the  apex,  or  to  the  superficial  car- 
diac space,  is  not  proof  of  regurgitation.  A  truly  regur- 
gitant murmur,  however,  may  be  too  feeble  to  be  trans- 
mitted beyond  the  apex  ;  the  proof  of  regurgitation  must 
then  be  based  on  other  evidence  associated  with  the 
murmur,  namely,  on  enlargement  of  the  heart  and  ab- 
normal modifications  of  the  heart-sounds. 

Mitral  obstruction  may  exist  without  incompetency 
of  the  mitral  valve,  as  shown  by  the  presence  of  a  mitral 
direct,  without  a  mitral  regurgitant,  murmur.  The  con- 
verse of  this  is  of  more  frequent  occurrence,  that  is,  re- 
gurgitation may  exist  without  obstruction.  The  absence, 
however,  of  a  mitral  direct  murmur  is  not  positive  proof 
against  mitral  obstruction,  for,  as  has  been  seen,  the 
production  of  a  characteristic  mitral  direct  murmur  re- 
quires the  obstruction  to  be  caused  by  an  adherence  of 
the  mitral  curtains  at  their  sides,  the  curtains  being 
sufficiently  flexible  to  vibrate  with  the  passage  of  the 
mitral  direct  current  of  blood.  Mitral  obstruction  and 
regurgitation  not  infrequently  coexist,  as  shown  by  the 
presence  of  both  the  mitral  direct  and  the  mitral  regur- 
gitant murmur. 

The  mitral  murmurs  do  not,  j^ei'  sc,  denote  the  amount 
of  obstruction  or  regurgitation,  or  of  both  combined. 
Information  with  reference  to  these  i)oInts  may  be  de- 
rived from  a  comparison  of  the  aortic  with  the  pulmonic 


VALVULAR    LESIONS.  225 

second  sound.  The  amount  of  obstruction  or  regurgi- 
tation, or  both,  is  great  in  proportion  as  the  aortic  sound 
is  weakened.  Per  contra,  there  can  be  but  little  ob- 
struction or  regurgitation  if  the  aortic  and  the  pulmonic 
second  sound  preserve  completely  or  nearly  their  normal 
relation  to  each  other  in  respect  of  intensity.  Infor- 
mation may  also  be  obtained  by  analyzing  the  first  sound 
as  heard  at  the  apex.  In  proportion  as  the  function  of  the 
mitral  valve  is  compromised  by  lesions,  the  valvular 
element  of  the  first  sound  at  the  apex  will  be  found 
deficient.  In  some  cases  the  first  sound  in  this  situation 
has  no  valvular  element,  presenting  only  the  characters 
of  impulsion. 

Enlargement  of  the  right  side  of  the  heart,  which 
results  from  mitral  obstructive,  and  regurgitant  lesions, 
is  a  criterion  of  the  amount  of  obstruction  and  regurgi- 
tation taken  in  connection  with  the  length  of  time  in 
which  they  have  existed.  Hypertrophic  enlargement 
of  the  right  ventricle  intensifies  the  pulmonic  second 
sound,  and  allowance  must  be  made  for  this  modifi- 
cation in  determining,  by  a  comparison  of  the  pulmonic 
and  the  aortic  sound,  the  degree  in  which  the  latter  is 
weakened. 

Aortic  Lesions. — Lesions  are  localized  at  the  aortic 
orifice  by  the  aortic  murmurs,  namely,  the  aortic  direct 
and  the  aortic  regurgitant  murmur.  Aortic  obstructive 
lesions  give  rise  to  an  aortic  direct  murmur;  but  it 
must  be  considered,  in  the  first  place,  that  an  aortic  di- 
rect murmur  may  be  inorganic,  and,  in  the  second  place, 
that,  if  the  murmur  be  organic,  it  may  be  produced  by 
lesions  which  occasion  no  obstruction,  and  are  conse- 
quently innocuous.  The  existence  of  obstructive  lesions 
must  be  determined   by  evidence  added  to  the  presence 


226  DISEASES    OF    THE    HEART. 

of  the  murmur.  This  ev^idence  is  either  impairment  or 
suppression  of  the  aortic  second  sound,  and  enkirgement 
of  the  left  ventricle.  If  the  lesions  which  occasion  ob- 
struction are  of  a  character  to  diminish  or  arrest  the 
movements  of  the  aortic  valve,  the  aortic  second  sound 
will  be  either  weakened  or  lost.  If  v^alvular  lesions  be 
limited  to  the  aortic  orifice,  the  degree  of  enlargement  of 
the  heart  is  a  criterion  of  their  pathological  importance. 

Regurgitant  lesions  at  the  aortic  orifice  give  rise  to 
an  aortic  regurgitant  murmur.  This  murmur,  of  course, 
is  always  proof  of  regurgitation;  but  the  murmur  gives 
no  definite  information  concerning  the  amount  of  incom- 
petency of  the  aortic  valve.  A  loud  murmur  may  be 
produced  by  a  regurgitant  stream  so  small  as  to  be,  for 
the  time,  insignificant;  and,  on  the  other  hand,  a  large 
regurgitant  current  may  give  rise  to  a  feeble  murmur. 
The  extent  to  which  the  valve  is  damaged  by  the  lesions, 
is  to  be  determined,  first,  by  either  weakness  or  suppres- 
sion of  the  aortic  sound,  and,  second,  by  the  degree  of 
enlargement  of  the  left  ventricle. 

Aortic  obstructive  and  regurgitant  lesions  are  often 
associated.  An  aortic  direct  and  an  aortic  regurgitant 
murmur  are  then  both  present,  with  a  weakened  aortic 
sound  or  its  suppression,  and  enlargement  of  the  left 
ventricle  according  to  the  amount  of  the  obstruction 
and  regurgitation,  togetlier  with  the  length  of  time 
during  which  the  latter  have  existed.  These  effects, 
and  not  the  intensity,  nor  the  pitch,  nor  the  quality  of 
the  murmurs,  are  indicative  of  their  pathological  impor- 
tance. 

Mitral  and  aortic  lesions  often  coexist,  giving  rise  to 
two,  three,  or  four  of  the  obstructive  and  regurgitant 
murmurs  in  the  left  side  of  the  heart.     In  addition  to 


TRICUSPID    AND    PULMONIC    LESIONS.  227 

the  murmurs  in  these  cases,  tlie  effects  of  tlie  combined 
lesions  are  shown  in  the  modification  of  the  heart-sounds, 
and  enlargement  of  both  sides  of  the  heart. 

Tricuspid  Lesions. — Tricuspid  obstructiv^e  lesions  are 
exceed  in  2:1  y  rare.  A  few  instances  of  the  kind  of  ob- 
struction  which  is  represented  by  a  presystolic  or  a  tri- 
cuspid direct  murmur,  haye  been  reported.  One  instance 
has  fallen  under  my  observation.  In  this  case,  as  in  the 
other  instances  which  have  been  reported,  the  tricuspid 
were  associated  with  mitral  lesions :  hence,  in  localizing 
an  obstructive  lesion  at  the  tricuspid  orifice,  the  presence 
of  the  presystolic  murmur  on  each  side  of  the  heart, 
that  is,  the  coexistence  of  mitral  and  the  tricuspid  direct 
murmur  is  to  be  determined.  This  point  has  already 
been  considered  [vide  page  212). 

Tricuspid  regurgitation  is  not  uncommon.  Generally 
the  insufficiency  is  caused  by  dilatation  of  the  right  ven- 
tricle occurring  as  an  effect  of  mitral  regurgitant  or  ob- 
structive lesions.  Tricuspid  regurgitation  is  not  always 
represented  by  murmur  ;  and  when  a  tricuspid  regurgi- 
tant murmur  is  present,  it  is  to  be  discriminated  from  a 
coexisting  mitral  regurgitant  murmur.  This  point  has 
been  considered  (vide  page  212). 

Pulmonic  Lesions. — As  compared  with  aortic  lesions, 
these  are  of  extremely  infrequent  occurrence,  and  they 
are  generally  congenital.  Lesions  giving  rise  to  a  pul- 
monic direct  murmur  may  be  localized  by  differentiating 
this  murmur  from  the  aortic  direct  murmur  (vide  page 
213).  It  is  to  be  considered  that  an  inorganic  pulmonic 
direct  murmur  is  not  infrequent.  Pulmonic  regurgi- 
tant lesions  can  only  be  diagnosticated  by  determining 
that  a  murmur  occurring  with  the  second  sound  of  the 


228  DISEASES    OF    THE    HEART. 

heart  is  produced  at  the  pulmonic  and  not  at  the  aortic 
orifice  (vide  page  213). 

Faifi/  Degeneration y  3Iyocarditis,  and  Softening  of  the 
Heart. — Fatty  degeneration  of  the  heart  is  not  repre- 
sented by  any  distinctive  signs,  but,  nevertheless,  the 
physical  diagnosis,  taking  into  account  the  clinical  his- 
tory, may  be  quite  positive.  The  signs  are  those  whicli 
denote  persistent  muscular  weakness  of  the  heart.  The 
apex-beat,  if  appreciable,  is  feeble.  The  intensity  of 
the  heart-sounds  is  diminished,  and  especially  the  inten- 
sity of  the  first  sound.  The  first  sound  may  be  even 
suppressed  over  the  apex,  the  second  sound  being  heard 
in  this  situation.  The  characters  of  the  first  sound 
which  belong  to  the  element  of  impulsion  are  especially 
impaired  or  lost,  the  sound  becoming  short  and  valvular, 
in  these  respects  resembling  the  second  sound.  Now 
these  evidences  of  weakened  muscular  power  occur  when 
the  weakness  is  merely  functional,  and  when  the  heart  is 
enlarged  by  predominant  dilatation.  But  functional 
weakness  is  generally  transient,  and  is  sufficiently  ex- 
plained by  the  existence  of  other  than  cardiac  disease. 
Enlargement  by  dilatation  is  readily  determined  by 
physical  signs.  If  the  heart  be  but  little,  or  not  at  all, 
enlarged,  and  pathological  conditions  adequate  to  ex- 
plain diminished  muscular  power  irrespective  of  cardiac 
disease  be  excluded,  and  at  the  same  time  the  signs 
being  connected  with  diagnostic  symptoms,  the  existence 
of  fatty  degeneration  may  be  determined  with  much  con- 
fidence. 

Fattv  deijeneratiou  mav  coexist  with  valvular  lesions 
and  enlargement  of  the  heart.  The  physical  diagnosis 
of  fatty  degeneration  under  these  circumstances  is  not  a 
simi)le  problem.     A  probable  diagnosis  may  be  made 


ENDOCARDITIS.  229 

wlien  the  amount  of  enlargement  seems  insufficient  to 
account  for  the  signs  denoting  muscular  weakness  of  the 
heart,  and  when  symptoms  belonging  to  the  clinical  his- 
tory point  to  fatty  degeneration. 

Softening  of  the  muscular  structure  of  the  heart,  oc- 
curring in  myocarditis,  in  continued  fever,  and  other 
general  diseases,  is  denoted  by  the  same  signs  which  are 
embraced  in  the  physical  diagnosis  of  fatty  degeneration, 
the  most  marked  evidence  being  notable  weakness,  with 
valvular  quality,  or  suppression,  of  the  first  sound  over 
the  apex  of  the  heart. 

Endocarditis. — The  physical  diagnosis  of  endocarditis 
relates  especially  to  its  occurrence  in  connection  with 
articular  rheumatism.  The  diagnostic  sign  is  a  mitral 
systolic  non-regurgitant  murmur  (vide  page  205).  The 
presence  of  this  murmur,  howev^er,  in  a  case  of  rheuma- 
tism, is  not  positive  proof  of  an  existing  endocarditis, 
more  especially  if  the  patient  have  previously  had  artic- 
ular rheumatism,  because  an  endocarditis  developed  in 
a  previous  attack  may  have  left  a  permanent  murmur. 
If  the  murmur  be  a  mitral  regurgitant  murmur,  and  the 
heart  be  enlarged,  it  is  quite  certain  that  endocarditis  has 
previously  occurred.  The  positive  proof  is  the  produc- 
tion of  the  murmur  during  an  attack  of  rheumatism, 
when  previous  examinations  made  after  the  commence- 
ment of  the  rheumatic  attack,  had  shown  that  there  was 
no  mitral  murmur.  An  aortic  direct  murmur,  in  cases 
of  rheumatism,  is  not  evidence  of  endocarditis,  because 
in  many  cases  of  rheumatism  this  murmur  occurs,  and 
is  to  be  regarded  as  inorganic. 

In  the  variety  of  endocarditis,  known  as  ulcerative, 
occurring  in  the  course  of  infectious  or  septic  diseases, 
and  sometimes  without  any  known  pathological  connec- 

20 


230  DISEASES    OF    THE    HEART. 

tion,  an  aortic  murmur  may  be  developed,  with  or  with- 
out a  coexisting  mitral  murmur,  owing  to  the  soft  masses 
present  on  the  valves. 

Endocarditis  is  probably  of  frequent  occurrence  as 
secondary  to  mitral  and  aortic  valvular  lesions  ;  but,  un- 
der these  circumstances,  a  physical  diagnosis  is  imprac- 
ticable. 

Pericarditis. — The  physical  diagnosis  of  pericarditis 
in  the  first  stage,  that  is,  prior  to  the  effusion  of  liquid^ 
is  to  be  based  on  a  pericardial  friction  murmur.  For- 
tunately for  diagnosis,  this  murmur  is  uniformly  present. 
Its  characters  as  contrasted  with  endocardial  murmurs 
have  been  stated  (vide  page  214).  The  presence  of  a 
pericardial  friction  murmur,  in  connection  with  symp- 
toms denoting  pericarditis,  renders  the  diagnosis  quite 
positive.  There  is,  however,  one  liability  to  error.  In 
some  cases  of  pleurisy  or  pneumonia  with  pleuritic  in- 
flammation, the  movements  of  the  heart  occasion  a  rub- 
bing together  of  the  roughened  pleural  surfaces,  and  in 
tills  way  a  cardiac  pleural  friction  murmur  is  produced. 
This  may  be  single  or  double,  and  when  double,  it  sim- 
ulates the  murmur  produced  within  the  pericardial  sac. 
It  is  limited  to  the  border  of  the  heart,  and  is  neither 
accompanied  nor  followe'd  by  pericardial  effusion.  Of 
course,  the  error  of  mistaking  a  cardiac  pleural  friction 
murmur  for  one  produced  within  the  pericardium,  can 
only  occur  when  pleurisy  exists,  either  as  a  primary 
affection  or  as  secondary  to  pneumonia. 

In  the  second  stage  of  pericarditis,  that  is,  after  the 
effusion  of  liquid  has  taken  place,  the  pericardial  friction 
murmur  often,  but  not  always,  disappears.  The  l)hysi- 
cal  diagnosis  in  this  stage  is  then  to  be  based  on  the 
signs  which  show  the  presence  of  a  greater  or  less  quan- 


PERICARDITIS.  231 

tity  of  liquid  within  the  pericardial  sac.  The  signs 
which  denote  pericardial  effusion,  and  its  amount  have 
been  stated  {vide  page  194).  With  a  moderate  effusion, 
the  apex  of  the  heart  is  raised,  and  the  apex-beat  may- 
be felt  in  the  fourth  intercostal  space,  and  removed  to 
the  left  of  its  normal  situation.  With  considerable  or 
large  effusion,  the  apex-beat  is  lost,  and  the  sounds  of 
the  heart  are  feeble  and  distant.  The  first  sound  loses 
the  characters  which  belong  to  the  element  of  impulsion, 
becoming:  short  and  valvular  like  the  second  sound. 

Increase  or  diminution  of  liquid  in  the  second  stage 
of  pericarditis  is  readily  determined  by  signs  obtained 
by  percussion  and  auscultation.  W^hen  the  quantity  is 
much  diminished,  the  friction  murmur,  if  it  have  been 
suppressed,  returns,  and  persists  until  the  pericardial 
surflices  become  agglutinated.  Not  infrequently,  by  aus- 
cultating when  the  body  of  the  patient  is  inclined  for- 
ward, a  friction  murmur  may  be  heard,  notwithstand- 
ing the  pericardial  sac  contains  a  large  quantity  of 
liquid. 

In  cases  of  chronic  pericarditis  with  very  large  effu- 
sion, dilatation  of  the  pericardial  sac  is  shown  by  signs 
obtained  by  percussion  and  auscultation.  There  is  no 
apex  impulse,  the  heart-sounds  are  feeble  and  distant, 
the  first  sound  being  short  and  valvular,  and  the  prse- 
cordia  may  be  notably  projecting. 

A  malignant  morbid  growth  filling  the  pericardial 
sac,  and  inclosing  within  it  the  heart,  may  give  rise  to 
all  the  signs  of  pericardial  effusion.  A  case  of  this  kind, 
in  a  young  subject,  has  fallen  under  my  observation. 

AVith  reference  to  diagnosis,  the  etiological  relations 
of  pericarditis  should  be  kept  in  mind.  These  are  acute 
articular  rheumatism,  Bright's  disease,  and  either  pleu- 


232  DISEASES    OF    THE    HEART. 

risy  or  pneumonia.  It  rarely  occurs  in  other  connec- 
tions, and,  as  an  idiopathic  affection,  it  is  extremely  rare. 

The  presence  of  air  and  liquid  within  the  pericardial 
sac  gives  rise  to  loud  splashing  sounds,  which,  occurring 
when  respiration  is  suspended,  and  when  pneumo-hy- 
drothorax  is  excluded,  are  at  once  diagnostic  of  pneu- 
mo-hydropericardium. 

Functional  Disorders. — Of  the  varied  forms  of  func- 
tional disorder  of  the  heart,  some  are  rare,  and  others 
are  of  frequent  occurrence.  A  rare  form  is  persistent 
frequency  of  the  heart's  action,  the  pulse  being  from  100 
to  120  or  more  per  minute,  for  weeks,  months,  and  even 
years.  This  form  of  disorder  exists  in  the  affection 
known  as  exophthalmic  goitre,  Graves's  or  Basedow's 
disease.  It  occurs,  also,  without  being  associated  with 
either  prominence  of  the  eyes  or  enlargement  of  the  thy- 
roid body.  In  a  rare  form,  the  opposite  of  this,  the  ac- 
tion of  the  heart  is  abnormally  infrequent,  the  pulse 
falling  to  50, 40,  30,or  less,  per  minute,  the  infrequency 
not  being  an  idiosyncrasy,  either  congenital  or  acquired, 
and  continuing  for  a  limited  period.  The  occurrence 
with  every  alternate  revolution  of  the  heart  of  a  ven- 
tricular systole  so  feeble  as  not  to  be  represented  by  a 
radial  pulse,  is  another  rare  form,  and  another  is  a  want 
of  synchronism  in  the  contraction  of  the  two  ventricles, 
giving  rise  to  reduplication  of  the  heart-sounds.  In  the 
more  common  forms  the  disorder  occurs  in  paroxysms, 
which  are  variable  in  duration  and  in  the  frequency  of 
their  occurrence,  the  heart,  in  the  paroxysms,  beating 
irregularly,  and  often  with  intermissions,  the  action  in 
some  instances  being  violent,  and  in  other  instances  feeble 
or  fluttering.  These  common  forms  are  embraced  under 
the  name  palpitation. 


FUNCTIONAL    DISORDERS.  233 

As  regards  the  physical  diagnosis,  all  the  forms  of  dis- 
order are  in  the  same  category;  in  all  the  functional 
character  of  the  affection  is  determined  by  exclnsion,  in- 
flammatory affections  and  lesions  being  excluded  by  the 
absence  of  their  diagnostic  signs.  In  whatever  way  the 
action  of  the  heart  is  disturbed,  however  great  may  be 
the  disturbance,  and  let  it  be  attended  with  ever  so  much 
distress  or  anxiety,  if  physical  exploration  furnish  no 
evidence  of  endocarditis,  pericarditis,  valvular  lesions, 
enlargement  of  the  heart,  fatty  degeneration,  or  heart- 
clot,  the  affection  is  to  be  considered  as  functional,  if 
purely  functional,  the  affection  is  unattended  by  danger, 
and  is  generally  remediable,  at  least  in  the  common 
forms.  Hence,  the  very  great  importance  of  a  })ositive 
diagnosis. 

In  one  point  of  view,  the  physical  diagnosis  in  func- 
tional disorders  may  be  said  to  rest,  not  on  negative,  but 
on  positive  evidence.  Percussion  and  auscultation  afford 
the  means,  not  only  of  excluding  inflammatory  affections 
and  lesions,  but  of  demonstrating  the  fact  that  the  organ 
is  sound,  at  least  as  regards  freedom  from  ordinary 
lesions.  That  its  size  is  normal,  is  shown  by  the  situa- 
tion of  the  apex-beat ;  by  ascertaining  the  lateral  bound- 
aries of  the  prsecordia  and  the  area  of  the  superficial 
cardiac  space.  That  the  valves  are  unaffected,  is  shown 
by  the  normal  characters  of  the  heart-sounds.  These 
positive  facts,  taken  in  connection  with  the  absence 
of  morbid  signs,  render  the  diagnosis  certain.  More- 
over, the  evidence,  positive  and  negative,  is  readily  and 
quickly  obtained.  Indeed,  the  time  required  for  reach- 
ing a  conclusion  is  so  brief,  that  it  is  often  politic  to  pro- 
long unnecessarily  the  examination  in  order  that  a  posi- 
tive assurance  of  the  soundness  of  the  organ  may  have 

21 


234  DISEASES    OF    THE    HEART. 

in  the  mind  of  the  patient  the  weight  which  is  desirable 
in  order  to  secure  relief  from  anxiety  and  apprehension. 
Functional  disorders  are  not  infrequently  associated 
with  lesions  with  which  they  have  no  essential  patholog- 
ical connection.  A  patient  with  lesions  which  are 
either  innocuous  or  attended  with  little,  if  any,  inconve- 
nience, may  suffer  from  disturbance  of  the  action  of  the 
heart  produced  by  causes  which  are  wholly  independent 
of  the  lesions.  There  is  a  liability,  in  these  cases,  to 
the  error  of  attributing  the  disorders  to  the  lesions,  and 
thus  forming  an  exaggerated  estimate  of  the  importance 
of  the  latter.  To  decide  how  much  of  tlie  disturbed 
action  of  the  heart  is  due  to  a  superadded  functional 
affection,  is  not  as  easy  as  to  determine  that  lesions  do 
not  exist.  The  decision  must  be  based  on  the  character, 
degree,  or  extent  of  the  lesions,  as  evidenced  by  the 
physical  signs.  In  this  connection  may  be  stated  a 
practical  maxim,  which  it  is  well  to  bear  in  mind,  whether 
functional  disorders  exist  or  not,  namely,  valvular  lesions 
rarely  give  rise  to  much  inconvenience  until  they  have 
led  to  enlargement  of  the  heart ;  and  enlargement,  either 
with  or  without  valvular  lesions,  as  a  rule,  does  not  lead 
to  the  serious  effects  which  are  characteristic  of  cardiac 
disease,  so  long  as  the  enlargement  is  due  to  hypertrophy 
and  not  to  dilatation. 

Thoracic  Aneurism. 

The  physical  conditions  incident  to  thoracic  aneurism, 
which  are  concerned  in  the  production  of  signs,  are,  the 
presence  of  a  tumor  within  the  chest,  of  variable  size, 
formed  by  the  aneurismal  sac  ;  the  passage  of  blood  into 
the  sac  with  each  ventricular  systole,  and  the  expulsion 
of  blood  in  the  diastole  by  the  recoil  of  the  coats  of 


THORACIC    ANEURISM.  235 

tlie  aneurism  ;  the  size  of  the  o[)etiing  into  the  sac  as 
affecting  the  quantity  of  blood  which  it  receives  with 
each  systole;  the  quantity  of  stratified  fibrin  which  the 
sac  contains;  the  point  of  connection  with  the  aorta  of 
the  aneurismal  tumor,  and  the  direction  from  this  point 
in  which  the  tumor  extends,  together  with  its  relations 
to  the  lungs,  the  trachea,  and  the  primary  bronchi. 

With  reference  to  diagnosis,  it  is  well  to  bear  in  mind 
that,  in  the  great  majority  of  cases,  an  aortic  aneurism 
is  connected  with  either  the  ascending  portion,  or  the 
junction  of  the  ascending  and  the  transverse  portion  of 
the  arch,  and  that  the  tumor  generally  extends  to  the 
right  in  a  lateral  or  antero-lateral  direction.  The  physi- 
cal diagnosis  is  more  easily  made  when  the  aneurismal 
tumor  is  thus  connected.  The  signs  are  less  available 
if  the  aneurism  arise  from  the  transverse  or  descending 
aorta,  and  especially  if  the  tumor  extends  in  a  direction 
downward  or  backward. 

An  aneurismal  tumor  which  has  made  its  way  through 
the  walls  of  the  chest,  or  which,  without  perforation, 
causes  a  circumscribed  bulging  obvious  to  the  eye  and 
touch,  presents  the  following  diagnostic  signs:  An  im- 
pulse is  seen  and  felt  which  is  synchronous  with  the 
ventricular  systole.  The  force  of  the  impulse  is  varia- 
ble, depending,  aside  from  the  force  with  which  the 
left  ventricle  contracts,  upon  the  size  of  the  orifice  be- 
tween the  sac  and  the  artery,  and  the  quantity  of  fibrin 
which  the  sac  contains.  A  vibration  or  thrill  \vith  each 
impulse  is  sometimes  a  marked  sign,  but  is  often  wanting. 
Frequently,  but  by  no  means  constantly,  a  systolic  murmur 
is  heard  over  the  tumor,  and  there  may  be  also  a  dias- 
tolic murmur  produced  by  the  passage  of  blood  from  the 
sac.     The  heart-sounds  over  the  tumor  are  more  or  less 


236  DISEASES    OF    THE    HEART. 

intense.  There  is  notable  clulness  on  percussion  over  an 
area  corresponding  to  the  space  witliin  the  chest  which 
the  tumor  occupies.  If  tlie  tumor  be  of  considerable  size, 
it  may  produce  condensation  of  lung  around  it ;  the  area 
of  dulness  on  percussion  will  be  in  this  way  extended 
beyond  the  limits  of  the  tumor.  Under  these  circum- 
stances, bronchial  respiration  and  bronchophony  may  be 
produced.  If  the  aneurismal  sac  be  beneath  the  integu- 
ment, there  may  be  to  the  touch  a  sense  of  fluctuation. 

With  the  foregoing  signs,  the  physical  diagnosis 
scarcely  admits  of  doubt.  Some  of  the  signs  may  be 
l)roduced  by  a  tumor,  not  aneurismal,  which  is  so  situated 
as  to  receive  and  conduct  the  aortic  impulse.  The 
chances  of  a  tumor  beino^  so  situated  as  to  simulate  the 
signs  of  an  aneurism  are  very  few.  I  have  met  with  a 
case  of  empyema  in  which  perforation  of  the  chest  took 
place  in  the  second  intercostal  space  on  the  right  side  of 
the  sternum,  giving  rise  in  this  situation  to  a  fluctuating 
tumor  which  had  a  strong  pulsation.  On  a  superficial 
examination  the  case  seemed  clearly  one  of  aneurism  ; 
but  an  examination  of  the  chest  showed  the  right  pleural 
cavity  to  be  filled  with  liquid,  and  a  puncture  in  the 
axillary  region  gave  exit  to  a  large  quantity  of  pus,  tlie 
pulsating  tumor  disappearing  after  a  certain  quantity  of 
the  purulent  liquid  had  escaped. 

When,  from  its  small  size  or  its  situation,  an  aneurismal 
tumor  does  not  come  into  contact  with  the  thoracic  wall, 
and  when  it  is  situated  beneath  the  sternum,  signs  ob- 
tained by  palpation  and  inspection  being  absent,  the 
physical  diagnosis  is  less  easy.  Important  signs  are, 
dulness  within  a  circumscribed  space  situated  in  the 
course  of  the  aorta;  an  abnormal  transmission  of  the 
heart-sounds  within  this  space,  and  the  presence  of  mur- 


TnORACIC    ANEURISM.  237 

murs.  These  signs  are  not  always  available,  and  when 
present  they  are  not  sufficient  for  a  positive  diagnosis. 
Other  physical  evidence  and  the  presence  of  certain 
symptoms  render  the  existence  of  aneurism  highly  prob- 
able either  with  or  without  the  foregoing  signs.  If  an 
aneurismal  tumor  press  upon  the  trachea,  it  occasions  a 
tracheal  sound,  or  stridor,  together  with  weakness  of  the 
respiratory  murmur  on  both  sides  of  the  chest.  If  the 
tumor  press  upon  a  primary  bronchus,  it  occasions  dimin- 
ished or  suppressed  respiratory  murmur  on  one  side,  and 
increased  respiratory  murmur  on  the  other  side  of  the 
chest.  These  physical  signs  should  always  lead  to  a 
suspicion  of  aneurism  in  a  person  forty  years  of  age. 
Symptoms  which  should  excite  this  suspicion  and  lead  to 
careful  physical  exploration  for  the  physical  signs  of 
aneurism,  are  dyspnoea  from  spasm  of  the  glottis,  and 
aphonia  or  impairment  of  the  voice  without  evidence  of 
laryngitis,  these  symptoms  denoting  either  excitation  or 
pressure  of  the  recurrent  laryngeal  nerve;  dysphagia 
from  obstruction  of  the  oesophagus ;  congestion  of  the 
face,  neck,  and  upper  extremities  from  obstruction  of  the 
vena  cava  or  the  vense  innominatse ;  inequality  of  the 
radial,  carotid,  and  subclavian  pulsation  on  the  two  sides, 
or  the  absence  of  pulsation  on  one  side,  and  contraction 
of  one  of  the  pupils.  These  symptoms  not  only  render 
probable  the  existence  of  aneurism,  but  indicate  its  situa- 
tion as  regards  the  aorta  and  the  direction  in  which  the 
aneurismal  tumor  extends. 

An  aneurism  may  be  suspected  when,  owing  to  shrink- 
age of  the  lung,  or  deformity  of  the  chest,  either  the 
aorta  or  the  pulmonary  artery,  just  above  the  heart,  is 
removed  laterally  from  its  normal  situation  and  brought 
into  contact  with  the  walls  of  the  chest  in  the  second 

22 


238  DISEASES    OF    THE    HEART. 

intercostal  space,  so  as  to  give  rise  to  an  appreciable  im- 
pulse. A  murmur  may  also  be  present  at  the  point  of 
impulse.  An  error  of  diagnosis  under  these  circum- 
stances is  avoided  by  finding  an  adequate  explanation  of 
the  signs  just  noted,  and  by  the  absence  of  other  signs 
and  of  symptoms  which  are  diagnostic  of  aneurism. 

In  conclusion,  an  aortic  murmur,  however  intense  or 
routrh,  is  never  evidence  of  aortic  aneurism. 


INDEX. 


Adventitious  respiratory  sounds 
or  rales,  106 

^Egophony,  125 

Amphoric  resouance  on  percussion, 
61 
respiration,  100 

Amplioric  voice,  130 

Aneurism,  thoracic,  232 

Aortic  direct  murmur,  207 
lesions,  diagnosis  of,  223 
regurgitant  murmur,  209 
diastolic  non-regurgitant  mur- 
mur, 209 

Apex-beat  of  heart,  modification  of, 
1S2 

Apoplexy,  pulmonary,  165 

Artery,  pulmonic,  and  aorta,  rela- 
tion of.  to  walls  of  chest,  184 

Asthma,  144 

Auscultation,  definition  of,  14 
in  disease,  85 
in  health,  65 

mediate  and  immediate,  66 
rules  in  practice  of,  68. 


Bronchial  rales,  dry,  112 
moist,  107 
respiration,  92 
"whisper  increased,  128 
Bronchitis  seated   in  large  bi-on- 
chial  tubes,  139' 
in  small  bronchial  tubes 
(capillary),  141 
Broncho-cavernous  respiration,  99 
Bronchophony,  123  | 

whispering,  124  , 

Broncho-vesicuiar  respiration,  94 


Carcinoma  of  lung,  168 
Cardiac  space,  superficial  and  deep, 
182 


Cavernous  rale,  117 
respiration,  97 
Chest,  anatomy  and  physiology  of, 
16 
regional  divisions  of,  33 
Cirrhosis  of  lung,  179 
Conditions,  morbid  physical,  inci- 
dent  to   different    dis- 
eases of  the  respiratory 
system,  19 
summary  of,  25 
physical,  of  the  heart  in  dis- 
ease, 190 
in  health,  182 
represented  by  amphoric  reso- 
nance, 61 
by    cracked  -  metal    reso- 
nance, 63 
by  dulness,  57 
by  flatness  on  percussion, 

55 
by  tympanitic  resonance, 

58 
by  vesicnlo-tymi)anitic  re- 
sonance, 60 
Coughing,  signs  obtained  by,  133 
Cracked-metal  resouance  on  per- 
cussion, 63 
Crepitant  rale,  114 


Diaphragmatic  hernia,  180 
Diseases  of  the  respiratory  system, 

phvsical  conditions  incident  to, 

19,'  135 
Dulness  on  percussion,  57 


Echo,  amphoric,  130 
Emphvsema,  pulmonary  or  vesicu- 
lar, 145 
Empyema,  150 
Endocarditis,  diagnosis  of,  228 


240 


INDEX. 


Exocardial  murmur.  214 
Expiratory  sound,  prolonged,  102 
Exploration,     physical,    dilicreut 
methods  of,  13 


Flatness  on  percussion.  55 
Fremitus,  normal,  vocal,  77 

in  different  regions.  80 
Friction  murmur,  i)ericaitlial,  214 

pleuritic,  rales,  118 


Gangrene,  puhnonary,  166 


Ha?morrhagic  infarctus,  165 
Heart,  abnormal  impiilses  of,  192 
diagnosis  of  diseases  of,  217 
enlargement  of,  190,  217 
fattv  degeneration  and  soften- 
ing of.  228 
first  sound  of,  intensified,  196 

weakened,  196 
functional  disorders  of,  230 
murmurs  of,  201 
physical  conditions  of,  in  dis- 
ease, 190 
in  health,  182 
diagnosis  of  diseases  of,  217 
second    sound,    aortic,  weak- 
ened, 197 
pulmonic,  weakened, 
198 
sounds  of,  185 
valvular  lesions  of,  193 
diagnosis  of,  223 
Heart-sounds,  abnormal  modifica- 
tions of,  195 
reduplication  of,  199 
Hernia,  diaphragmatic,  180 
Hydrothorax,  150 


Indeterminate  rales.  121 
Infarctus,  luemorrhagic,  165 
Inspiratory  sound  shortened,  101 
Intensity  of  normal  and  abnormal 

sounds,  differences  of,  27 
Interrupted  respiration,  104 


Laryngeal   and   tracheal   respira- 
tion, 70 
rales,  106 


Larvnx  and  trachea,  affections  of, 

137 
Lesions,  valvular,  of  heart,  193, 223 

diagnosis  of,  223 
Lobular  pneumonia,  141 
Lobules,  pulmonary,  collapse   of, 

141 


Metallic  tinkling,  118,  133 
Mitral  lesions,  diagnosis  of,  223 
Murmur,  aortic  direct,  207 

diastolic  or  non-regurgi- 

tant,  209 
regurgitant,  209 
cardiac,  200 
mitral  direct,  204 

regurgitant,  206 
normal  vesicular,  72 
pericardial  or  friction,  214 
pulmonic  direct,  212 
regurgitant,  213 
systolic     non-regurgitant     or 

intra-veutricular.  206 
tricuspid  direct.  211 
regurgitant.  212 
vesicular  diminished,  87 
increased,  87 
Murmurs,  endocardial  coexisting, 
210 
facts  of  importance  relating  to, 
213 


CE^ema,  pulmonary,  16'! 


Pectoriloquy,  129 
Percussion,  definition  of,  13 

in  health,  38 

in  disease.  54 

modes  of  performing,  3-S 

objects  of,  39 

respiratory,  51 

rules  in  practice  of,  51 

signs  of  disease  furnished  bv, 
54 

sense  of  resistance  in,  63 
Pericardial   or  friction    murmur, 
214 

sac.  liquid  within,  194 

surfaces,  roughness  of,  194 
Pericarditis,  diagnosis  of,  228 
Phthisis,  172 

fibroid,  179 


INDEX. 


241 


Pitcli    of    nonuiil    and    abnormal 

Kounds,  27 
ricnnil  rales,  118 
IMcurisy,  aculc  and  chronic,  150 
I'ncunioiiia,  acntc;  lobar,  150 

circumscribed,  1()5 

embolic,  1()5 

interstitial,  17J) 

lobular,  111 
Pncumo-bydrothorax,  157 
l*iieumo-pyotiiorax,  157 
rneumotborax,  157 
rrau-.ordia,  1S2 
Pulmonary  ai)oi)lcxy,  105 

gangrene,  KiG 

(cibMua,  1()7 
Pulmonic  direct  murmur,  212 

lesions,  dia,t;'nosis  of,  227 

regurgitant  murmur,  213 


Quality  of  normal  and   abnormal 
sounds,  28 
terms  denoting,  30 


Eale,  cavernous  or  gurgling,  117 
crepitant  or  vesicular,  114 
indeterminate,  121 
metallic  tinkling,  120 
splashing  or  succussion,  121 
Ealcs,  10(5 

fine  bubbling  or  subcrcpitant, 

109 
dry  bronchial,  112 
laryngeal  and  tx'acheal.  lOG 
moist  bronchial,  107 
pleural  or  friction,  118 
Regions,  division  of  chest  into,  33 
sections  of  chest  corresponding 
to,  34 
Res(mancc,  amphoric,  61 
crack(xl-metal,  (J3 
diminished,  or  dulness,  57 
in  dillercnt  regions,  80 
normal,  vesicular,  on  percus- 
sion, 40 
vocal    over     laiynx    and 
trachea,  76 
on   percussion,  absence  of,  or 

flatness,  55 
over  chest,  78 
tympanitic,  58 
variations  in  different  regions 

of  chest,  43 
vesiculo-tympanitic,  60 


Respiration,    iibiKniual     modifica- 
tions of,  H() 
amphoric,  100 
bronchial  or  tubular,  92 
l)roncho-caveriious,  99 
broncho-vesicular,  94 
cavernous,  97 
diminislu;d,  87 
in  difi'erent  regions,  74 
interrupted,  101 
normal,    laryngi'al,    and     tra- 
cheal, 70 
vesicular  murmur  of,  72 
srippressed,  90 

vesicular      murmur      of,    in- 
creased, 87 
Respiratory  organs,  anatomy  and 
physiologj''  of,  16 
physical  conditions  inci- 
dent to  diseases  of,  19, 
25 


Signs,  arrangement  of,  105 

by  percussion  in  disease,  54 

in  health,  39 
healthy  and  morbid,  distinc- 
tive characters  of,  26 
obtained  by  coughing,  133 
physical  definition  of,  14 
respiratory,  in  disease,  86 

in  health,  69 
significance  of,  32 

as  representing  physi- 
cal conditions,  32 
vocal,  in  health,  76 
of  disease,  122 
Sounds,  differences  of  intensity  in, 
27 
in  pitch,  27 
in  quality,  28 
normal  and  abnormal,  14 
Splashing    or  succussion    sounds, 

121 
Stethoscope,  advantages  of,  66 
binaural,  66 


Tricuspid,  direct  murmur,  211 
lesions,  diagnosis  of,  227 
regurgitant  murmur,  212 

Tuberculosis,  acute,  171 

Tumor  within  the  chest,  168 

Tussive  signs,  133 

Tympanitic  resonance  on  percus- 
sion, 58 


242 


INDEX. 


Vesiculo-tympanitic  resonance  on 

percussion,  60 
Vocal  fremitus,  diminished  or  sup- 
pressed, 133 
increased,  125 
resonance,     diminished     and 
suppressed,  131 
increased,  125 
signs  of  disease,  122 


Voice,  amphoric,  130 


Whisper,  hronchial,  increased,  128 
cavernous,  129 
in  different  regions,  83 
normal  bronchial,  82 

Whispering  pectoriloquy,  129 


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AMERICAN  SYSTEM  OF  GYNAECOLOGY.     In    treatises  by  various 
■"■     authors.     In  two  large  octavo  volumes.      {In  active  preparatiuyi.) 

ASHHURST  (JOHN.  Jr.)  THE  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  FOR  THE  USE  OF  STUDENTS  AND  PRACTI- 
TIONERS. Third  and  revised  edition.  In  one  large  and  handsome 
octavo  volume  of  1060  pages,  with  555  woodcuts.  Cloth,  $G ; 
leather,  ^7  ;   very  handsome  half  Russia,  raised  bands,  $7  50. 


2  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

ASHWELL  (SAMUEL).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  WOMEN.  Third  American  from  the  third  London  edi- 
tion. In  one  octavo  volume  of  520  pages.  Cloth,  S3  50. 
ATTFIELD  (JOHN).  CHEMISTRY;  GENERAL,  MEDICAL  AND 
PHARMACEUTICAL.  Eighth  edition,  revised  by  the  Author.  In 
one  12mo.  vol.  of  701  pages,  with  87  illu.?.  Clo.,  $2  50;  leather,  $3  00. 

BAIRD  (ROBERT) .    IMPRESSIONS  AND  EXPERIENCES  OF  THE 
WEST  INDIES.     1  vol.  royal  12rao.     Cloth,  75  cents. 
BARLOW    (GEORGE    H.)     A   MANUAL  OF   THE  PRACTICE   OF 
MEDICINE.     In  one  8vo.  volume  of  603  pages.     Cloth,  $2  50. 
BARNES  (FANCOUdT).     A  MANUAL  OF  MIDWIFERY  FOR  MID- 
WIVES.    In  onel2mo.  vol.  of  197  pp.,  with  SOillus.  Cloth,  $1  25. 
BARNES    (ROBERT).     A  PRACTICAL  TREATISE  ON    THE  DIS- 
EASES OF  WOMEN.    Third  American  from  3d  English  edition.  In 
one  8vo.  vol.  of  about  800  pages,  with  about  200  illus.     iPreparijig.) 

BARNES  (ROBERT  and  FAN  COURT).  A  SYSTEM  OF  OBSTET- 
RIC  MEDICINE  AND  SURGERY,  THEORETICAL  AND  CLIN- 
ICAL. The  Section  on  Embryology  by  Prof.  Milnes  Marshall. 
In  one  large  octavo  volume.      {Preparing.) 

BARTHOLOW  (ROBERTS).  A  PRACTICAL  TREATISE  ON  ELEC- 
TRICITY AS  APPLIED  TO  THE  PRACTICE  OF  MEDICINE. 
Second  edition.  In  one  very  handsome  octavo  volume  of  292  pages, 
with  109  illustrations.     Cloth,  $2  60. 

BASHAM  (W.  R.)  RENAL  DISEASES  ;  A  CLINICAL  GUIDE  TO 
THEIR  DIAGNOSIS  AND  TREATxMENT.  In  one  12mo.  volume 
of  304  pages,  with  illustrations.     Cloth,  $2  00 

BELLAMY'S   MANUAL  OF  SURGICAL  ANATOMY.     In  one  royal 
]2mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2  25. 
BLANDFORD  (G.  F.)     INSANITY  AND  ITS  TREATMENT.     Lec- 
tures on  the  Treatment,  Medical   and  Legal,  of  Insane  Patients. 
In  one  very  handsome  octavo  volume. 

BLOXAM  (C.  L).  CHEMISTRY,  INORGANIC  AND  ORGANIC. 
With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  about  700  pages,  with  about 
300  illustrations.     {Inpress.) 

BRISTOWE  (JOHN  SYER).  A  TREATISE  OF  THE  PRACTICE  OP 
MEDICINE.  Second  American  edition,  revised  by  the  Author. 
Edited  with  additions  by  James  H.  Hutchinson,  M.D.  In  one 
handsomeSvo.  volume  of  1085  pages.  Cloth,  $5  00  ;  leather,  $6  00; 
very  handsome  half  Russia,  raised  bands,  $6  50. 

BROWNE  (EDGAR  A.)  HOW  TO  USE  THE  OPHTHALMOSCOPE. 
Elementary  instruction  in  Ophthalmoscopy  for  the  Use  of  Students. 
In  one  email  12mo.  volume  of  116  pages,  with  35  illust.     Cloth,  %\. 

BROWNE  (LENNOX).  THE  THROAT  AND  ITS  DISEASES.  New 
edition.  In  one  handsome  imperial  8vo.  volume,  with  12  colored 
plates,  120  typical  illust.  in  color  and  50  woodcuts.     {Prepari7tg .) 

BRUNTON  (T.  LAUDER).  A  MANUAL  OF  MATERIA  MEDICA 
AND  THERAPEUTICS;  including  the  Pharmacy,  the  Physiologi- 
cal Action  and  the  Therapeutical  Uses  of  Drugs.  In  one  handsome 
octavo  volume,     (hi  p?-ess.) 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Third 
American  from  the  third  English  edition.  Edited,  with  ad'litions, 
by  J.  B.  Roberts,  M.D.  In  one  imperial  octavo  volume  of  1009 
page.s,  with  7:^5  illustrations.  Cloth,  !i!6  50;  leather,  $7  60;  very 
handsome  half  Russia,  raised  bands,  $8. 

BUMSTEAD  (F.J.)  and  TAYLOR  (R  W  )  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.     Fifth  edition,  re- 
vised and  enlarged,  by  R.  W.  Taylor,  M.D.    In  one  very  handsome 
8vo.  volume  of  850  pages,  with  about  150  illustrations.    {Shortly.) 
ANDCULLERIER'S  ATLAS  OF  VENEREAL.  See  "CcLLERiEn. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  3 

BURNETT  (CHARLES  H.)  THE  EAR:  ITS  ANATOMY,  PIIYSI- 
OLOGY  AND  DFSEASES.  A  Practical  Treatise  for  the  Use  of 
Students  and  Practitioners.  In  one  handpome  octavo  volume  of 
619  paRes,  with  87  illustrations.  Cloth  $4  50;  leather,  $5  50  ; 
very  handsome  half  Russia,  rai?e1  bands,  $6. 

CAMPBELL'S  LIVES  OF  LORDS  KEN  YON,  ELLENBOROUGH  AND 
TENTERDEN.  Being  the  third  volume  of  "  Campbell's  Lives  of 
the  Chief  Justices  of  England."    In  one  crown  octavo  vol.  Cloth,  $2. 

CARPENTER  (WM.  B.)  PRINCIPLES  OF  HUMAN  PHYSIOLOGY. 
A  new  American,  from  the  eighth  English  edition.  In  one  large 
8vo.  volume  of  1088  pages,  with  373  illustrations.  Cloth,  $5  50; 
leather,  raised  bands,  $0    50  ;   half  Russia,  raised  bands,  $7. 

PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN 

HEALTH  AND  DISEASE.    New  Ed'tion,  with  a  Preface  by  D.  F. 
Condie,  M.D.     One  1  2mo.  volume  of  I  78  pages.    Cloth,  60  cents. 

CARTER  (R.  BRUDENELL).  A  PRACTICAL  TREATISE  ON  DIS- 
EASES  OF  THE  EYE.  With  additions  and  test-types,  by  John 
Green,  M.D.    In  oneSvo.  vol.of500  pages,  with  124  illustrations. 

CENTURY  OF  AMERICAN  MEDICINE.— A  History  op  Medicine  in 
Amkuica,  1776-1876.  In  one  12mo.  vol.  of  366  pages.  Cloth,  $2  25. 
CHADWICK  (JAMES  R.)  A  MANUAL  OF  THE  DISEASES  PECU- 
LIAR TO  WOMEN.  In  one  12mo.  vol  ,  with  illust.  {Preparin^r.) 
CHAMBERS  (T.  K.)  A  MANUAL  OF  DIET  IN  HEALTH  AND 
DISEASE.  In  one  handsome  8vo.  vol.  of  302  pages.  Cloth,  $2  75. 
CHURCHILL  (FLEETWOOD).  ESSAYS  ON  THE  PUERPERAL 
FEVER.  In  one  octavo  volume  of  464  pages.  Cloth,  $2  50. 
CLASSEN'S  QUANTITATIVE  ANALYSIS.  Translated  by  Edgar  F, 
Smith,  Ph.D.  In  one  12mo.  vol  of  324  pp.,  with  36  illus.  Cloth.  $2  00. 
OLELAND  (JOHN)  A  DIRECTORY  FOR  THE  DISSECTION  OF 
THE  HUxMAN  BODY.  In  one  12mo.  vol.  of  178  pp.  Cloth,  $125. 
CLOWES  (FRANK).  AN  ELEMENTARY  TREATISE  ON  PRAC- 
TICAL CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANA- 
LYSIS. FromtheThirdEng.  Ed.  In  one  12mo.  vol.  Cloth,  $2  50. 
COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  octavo 
volume  of  about  900  pages,  with  339  fine  engravings.  (Shortly.) 
COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND 
PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  American 
Practice.  By  Thos.  C.  Stellwagen,  M.  A.,  M.  D.,  D.D.S.  In  one  hand- 
some 8vo.  vol.  of  412  pp  ,  with  331  illus.  Cloth,  $3  25. 
CONDIE  (D.FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES  OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  vol.  of  719  pages.     Cloth,  $5  25  ;  leather,  :56  25. 

COOPER  (B.B.)  LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  SURGERY.  In  one  largeSvo.  vol.  of  767  pages.  Cloth.  $2  00. 
GDRNIL  (V.)  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS 
AND  TREATMENT.  Translated,  with  notes  and  additions,  by  J. 
Henry  C  Simes,  M.D  ,  and  J.  William  White,  M.D.  In  one  8vo. 
volume  of  461  pages,  with  84  illustrations.     Cloth,  $3  75. 

OORNIL  (V.).  AND  HANVIER  (L.)  MANUAL  OF  PATHOLOGICAL 
HISTOLOGY.  Translated,  with  Notes  and  Additions,  by  E.  0. 
Shakespeare,  M.D.,  and  J.  Henry  C.  Simes,  M.D.  In  one  octavo 
volume  of  800  pages,  with  360  illustrations.  Cloth.  $5  50  ;  leather, 
$6  50;  very  handsome  half  Russia,  raised  bands,  $7. 

OULLERIER(A.)  AN  ATLAS  OF  VENEREAL  DISEASES.  Trans- 
lated and  edited  by  Frkkman  J.  Bumstead,  M.D.,  LL.D.  A  large 
imperial  quarto  volume,  with  26  plates  containing  about  150  figures, 
beautifully  colored,  many  of  them  life-size.  In  one  vol.,  strongly 
bound  in  cloth,  $17. 

D ALTON  (J.  C.)  A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Sev- 
enth  edition,thoroughlyrevised,and  great lyimp'oved.  In  one  very 
handsome  8vo.  vol.  of  722  pages,  with  252  illustrations.  Cloth, 
$5  ;  leather,  $6;   very  handdome  half  Russia,  $6  50. 


D 


4  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

D ALTON    (J    C)      THE    TOPOGRAPHICAL   ANATOMY   OF   THE 
BEAIN.     In  one  qu.-irto  volume  of  200  pages,  with  94  photographic 
pliites  and  many  woodcuts.      {Frepariyig.) 

DANA  (JAMES  D.)  THE  STRUCTUKE  AND  CLASSIFICATION  OF 
ZOOPHYTES.    Withillust.onwood.  In  oneimp.  4to.  vol.  Clo.,$4. 

AVIS  (F.  H.)  LECTURES  ON  CLINICAL  MEDICINE.  Second 
ed.,  revised  and  enlarged.  In  one  12mo.  vol.  of  287  pp.  Cloth,  $175. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  Svo.voL 
of  700  pages,  with  300  illustrations.     Cloth,  $4. 
DON  QUIXOTE  DE  LA  MANCHA.   Illustratededition.    In  two  hand- 
some crown  8vo.  vols.     Cloth,  $2  50  ;  half  morocco,  $3  70. 
DRUITT  (ROBERT).    THE  PRINCIPLES  AND  PRACTICE  OF  MO- 
DERN SURGERY.     A  revised  American,  from  the  eighth  London 
edition.     In  one  octavo  volume  of  687  pages,  with  432  wood  en- 
gravings.    Cloth,  $4;  leather,  $5. 
DUNCAN  (J.  MATTHEWS)     CLINICAL  LECTURES  ON  THE  DIS- 
EASES OF  WOMEN.     Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.    Cloth,  $1  50. 

DUNGLISON  (ROBLEY).  MEDICAL  LEXICON;  A  Dictionary  of 
Medical  Science.  Containing  a  concise  explanation  of  the  various 
subjects  and  terras  of  Anatomy,  Physiology,  Pathology,  Hj'giene, 
Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medi- 
cal Jurisprudence  and  Dentistry  ;  notices  of  Climate  and  of  Mineral 
AVaters  ;  Formulae  forOfficinal,  Empirical  and  Dietetic  Preparations; 
with  the  accentuation  and  Etj^mology  of  the  Terms,  and  the  French 
and  other  Synonymes.  New  edition.  In  one  very  large  royal  Svo. 
vol.  Cloth,  $6  50;  leather,  $7  50  ;  half  Ru.^sia,  raised  bands,  $8. 

EDIS  (ARTHUR  W).  DISEASES  OF  WOMEN.  A  Manual  for  Stu- 
dents and  Practitioners.  In  one  handsome  Svo.  vol.,  of  576  pp., 
with  148  illustrations.     Cloth,  $3;  leather,  $4. 

ELLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY. 
Being  a  Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection. 
From  the  eighth  and  revised  English  edition.  In  one  very  handsome 
octavo  volume  of  716  pages,  illustrated  by  249  engravings  on  wood. 
Cloth,  $4  25  ;   leather,  $5  25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRACTICE 
OF  GYNAECOLOGY,  forthe  use  of  Students  nnd  Practitioners.  Sec- 
ond edition,  enlarged  and  revised.  In  one  large  Svo.  vol.  of  879 
pp.,  with  133  original  illustrations.  Cloth,  $5;  leather,  $6;  very 
handsome  half  Russia,  raised  bands,  $0  50. 

ERICHSEN  (JOHN  E.)  THE  SCIENCE  AND  ART  OF  SURGERY. 
A  new  American,  from  the  eighth  enlarged  and  revised  London 
edition.  In  two  large  octavo  volunnes  of  about  2000  pages,  with 
about  900  illustrations.      (Prej>artng.) 

ESMARCH  (FRIEDRICH).  EARLY  AID  IN  INJURIES  AND 
ACCIDENTS.  In  one  small  12mo  volume  of  109  pages,  with  24 
illustrations.     Cloth,  75  cents.      (Just  ready.) 

TiARQUHARSON    (ROBERT).      A    GUIDE   TO    THERAPEUTICS. 

•L  Third  American  edition,  specially  revised  by  the  Author.  Edited, 
with  ad  litions.embracingthe  U  S.  Pharmacopoeia,  by  Frank  Wood- 
bury. M.  D.  In  one  royal  12mo.  volume  of  624  pages.  Cloth, 
$2  25.      {Just  ready.) 

fENWICK  (SAMUEL).  THE  STUDENTS'  GUIDE  TO  MEDICAL 
DIAGNOSIS.  From  the  third  revised  and  enlarged  London  edi- 
tiim.     In  oneroyjil  1  2mo.  volume  of  32S  pages.     Cloth,  $2  25. 

FINLAYSON  (JAMES).  CLINICAL  DIAGNOSIS.  A  Handbook  for 
Students  and  Practitioners  of  Med;cine.  In  one  handsoiue  Svo. 
vol.  of  540  pages,  with  85  woodcuts.     Cloth,  $2  63. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  5 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Fifthedition,  thoroughly  revised  ;in<l 
largely  rewritten.  In  one  large  8vo.  vol.  of  11.50  pages  Cloth, $6  50  ; 
leather,  $6  50;  very  handsome  half  Kus«ia,  $7. 

AMANUALOF  AUSCULTATION  AND  PERCUSSION;  of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  a*nd  of  Tho- 
racic Aneurism.  Third  edition,  revised  and  enlarged.  In  one 
handsome  royal  12mo.  volume  of  240  pages.  Cloth,  $1  63.  {Just 
ready.) 

APRACTICALTREATISEONTHEDIAGNOSISANDTREAT- 

MENT  OF  DISEASES  OF  THE  HEART.  Second  edition,  enlarged. 
In  one  octavo  volume  of  550  pages.     Cloth,  $4  00. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RESPIRATORY  ORGANS.  Second  and  revised 
edition.     In  one  octavo  volume  of  591  pages.     Cloth,  $4  50. 

CLINICAL  MEDICINE.     A  SYSTEMATIC    TREATISE  ON 

THE  DIAGNOSIS  AND  TREATMENT  OF  DISEASE.  Designed 
for  Students  and  Practitioners  of  Medicine.  In  one  handsooae  octavo 
volume  of  799  pages.  Cloth,  $4  50;  leather,  $5  50  ;  very  handsome 
half  Russia,  raised  bands.  $6  00 

MEDICAL  ESSAYS     In  one  12ino.  vol.,  pp  210.     Cloth,  $138. 

ON  PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY, etc., 

a  series  of  Clinical  Lecture.s.   InoneSvo  vol.. pp. 442.  Cloth,  $3  50, 

THE    PHYSICAL    EXPLORATION    OF    THE    LUNGS    BY 

MEANS  OF  AUSCULTATION  AND  PERCUSSION.  In  one  small 
12mo.  volume  of  83  pages.      Cloth.      {Just  ready.) 

THE    PHYSICAL    EXPLORATION    OF    THE    LUNGS,    BY 


MEANS    OP    AUSCULTATION    AND    PERCUSSION.      In    one 
small  12mo.  volume  of  83  pages.      Cloth,  $1.      {Just  ready.) 

FOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  Second 
Am.  from  the  last  Lond.  edition,  with  extensive  notes  and  additions 
by  E.  T.  Reichert,  M  D.  In  one  large  12mo.  vol.  of  999  pages,  with 
259  illustrations      Cloth,  $3  25;  leather,  S3  75. 

A  TEXT-BOOK  OF  PHYSIOLOGY.     English  Student's  edition. 

In  one  handsome  12mo.  vol.  of  804  pp  ,  with  72  illus.    Cloth,  $3  00. 

pOTHERGILL'S  PRACTITIONER'S  HANDBOOK  OF  TREATMENT. 

J-      Second  edition,  revised  and  enlarged.     In  one  handsome  octavo 

vol.  of  about  650  pp.    Cloth,  $4  00;  very  handsome  half  Rus.,  $5  50, 

pOWNES  (GEORGE).  A  MANUAL  OF  ELEMENT  ARYCHEMISTRY, 
•*-      A  new  American,  from  the  twelfth  English  edition.     In  one  royal 

12mo.  volume  of  1031  pages,  with  1  77  illustrations,  and  one  colored 

plate.     Cloth,  $2  75  ;  leather,  $3  25. 

FOX  (TILBURY).  EPITOME  OF  SKIN  DISEASES,  with  Formulae. 
For  Students  and  Practitioners.  Third  Am.  edition,  revised  by 
the  Author  and  T.  C.  Fox.     In  one  small  12mo.  vol.     {hi  press.) 

FULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physic.il  Diagnosis,  Symptoms  and 
Treatment.   From  2d  Eng.  ed     In  1  «vo.  vol.,  pp.  475.   Cloth,  $3  50. 

GALLOWAY  (ROBERT).     A  MANUAL  OF  QUALITATIVE  ANAL- 
YSIS.     From  the  sixth  London  edition.      (Preparifig.) 
GIBNEY   (V,  P  ).     ORTHOPAEDIC  SURGERY.     For  the  use  of  Prac- 
titioners and  Students.      In  one  handsome  octavo  volume  profusely 
illustrated.      (Freparijig.) 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SURGERY.    In  two 
octavo  volumes  of  about  1000  pages.     Leather,  $6  50. 
GLUGE  (GOTTLIEB).   ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated  by  Joseph   Leidy,  M.D.,  Professor  of  Anatomy  in   the 
University  of  Pennsylvania,  Ac.     In  one  imperial  quarto  volume 
with  320  copperplate  figures,  plain  and  colored.     Cloth,  $4. 


6  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
Edited  by  T.  Pickering  Pick,  F.R  C.S.  A  new  American,  from  the 
tenth  and  enlarged  London  edition.  To  which  is  added  Holden's 
"Landmarks,  Medical  and  Surgical,"  with  additions  by  VV.  W. 
Keen,  M.D.  In  one  imperial  octavo  volume  of  1020  pages,  with 
560  large  and  elaborate  engravings  on  wood.      {Nearly  ready.) 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND 
MORBID  ANATOMY.  Fifth  American,  from  the  sixth  London 
edition.  In  one  handsome  octavo  volume  of  about  400  pages,  with 
about  150  illustrations.      (Preparing  ) 

GREENE  (WILLIAM  H.)  A  MANUAL  OF  MEDICAL  CHEMISTRY. 
For  the  Use  of  Students.  Based  upon  Bowman's  Medical  Chem- 
istry. In  one  royal  12mo.  volume  of  310  pages,  with  74  illustra- 
tions. Cloth,  $1  75. 
GRIFFITH  (ROBERT  E.)  A  UNIVERSAL  FORMULARY,  CON- 
TAINING THE  METHODSOF  PREPARING  AND  ADMINISTER- 
ING OFFICINAL  ANDOTHER  MEDICINES.  Thirdand  enlarged 
edition.  Edited  by  John  M.  Maisch,  Phar.D.  In  one  large  8vo. 
vol.  of  775  pages,  double  columns.     Cloth,  $4  50  ;  leather,  $5  50. 

GROSS  (SAMUEL  D.)  A  PRACTICAL  TREATISE  ON  THE  Dis- 
eases, Injuries  and  Malformations  of  the  Urinary  Bladder,  the  Pros- 
tate Gland  and  the  Urethra.  Third  edition,  thoroughly  revised 
and  much  condensed,  by  Samuel  W.  Gross,  M.D.  In  one  octavo  vol- 
ume of  574  pages,  with  170  illus.     Cloth.  $4  50. 

A  SYSTEM  OF  SURGERY,  PATHOLOGICAL,  DIAGNOSTIC, 

THERAPEUTIC  AND  OPERATIVE.  Sixth  edition,  thoroughly 
revised.  In  two  imperial  octavo  volumes  containing  2382  pages, 
with  1623  illustrations.  Strongly  bound  in  leather,  raised  bands, 
$15;  very  handsome  half  Rus.<!ia,  raised  bands,  $16. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE 


AIR  PASSAGES.     Inone  8vo.  vol.  of  468  pnges.    Cloth,  $2  75. 

GROSS  (SAMUEL  W.)  A  PRACTICAL  TREATISE  ON  IMPO- 
TENCE, STERILITY,  AND  ALLIED  DISORDERS  OF  THE 
MALE  SEXUAL  ORGANS.  Second  edition.  In  one  handsome 
octavo  vol.  of  168  pp.,  with  16  illust.     Cloth,  $1  50.     (Just  ready .) 

GUSSEROW  (A.)  A  TREATISE  ON  UTERINE  TUMORS.  Revised  by 
the  Author,  and  translated  by  Edmund  C.  Wendt,  M.D. ,  with  addi- 
tions by  the  translator  and  Nathan  Bozeman,  M.D.  In  one  8vo. 
volume  of  about  400  pages,  with  many  illustrations.      (Preparing.) 

GYNECOLOGICAL  TRANSACTIONS.  Vol.  VI.  (1881  )  In  one  very 
handsome  octavo  volume  of  549  pages,  with  illustrations.  Cloth, 
$6.     Vols.  I.,  III.,  IV  ,  v.,  each  $5.     Set  (6  vols.)  $30. 

HABERSHON  (S.  0.)  ON  THE  DISEASES  OF  THE  ABDOMEN, 
AND  OTHER  PART8  OF  THE  ALIMENTARY  CANAL.  Second 
American,  from  the  third  English  edition.  In  one  handsome  8vo. 
volume  of  554  page.?,  with  illus.      Cloth,  $3.50. 

HALL  (MRS.  M.)  LIVES  OF  THE  QUEENS  OF  ENGLAND  BEFORE 
THE  NORMAN  CONQUEST.  In  one  handsome  8vo.  vol.  Cloth, 
$2  25  ;  crimson  cloth,  $2  50  ;  half  morocco,  $3. 

HAMILTON  (ALLAN  McLANE)      NERVOUS   DISEASES,    THEIR 
DESCRIPTION  AND  TREATMENT.    Second  and  revised  edition 
In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 

HAMILTON  (FRANK  H.)  A  PRACTICAL  TREATISE  ON  FRAC- 
TURES AND  DISLOCATIONS.  Sixthedition,  thoroughly  revised. 
In  one  handsome  8vo.  vol.  of  909  pages,  with  352  illus.  Cloth, 
$5  50;   leather.  $6  50;   very  handsome  half  Russia,  $7. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
vol.  669  pp    with  144  illustrations.     Cloth,  $2  75;  half  bound,    S3. 

A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     In  one 

royal  12mo.  volume  of  310  pnges,  with  220  illust.     Cloth,  $1  75. 


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ITARTSHORNE    (HENRY).     A  COXSPECTUS  OF  THE  MEDICAL 

-•-*•    SCIENCES.    Comprising  M.inualF  of  Anatomy,  Phv.*ioIogy   Chem- 

istry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and'obnet- 

rics.     Second  edition.     In  one  royal  12mo.  volume  of  1028  pages 

with  477  illustrations.     Cloth,  $4  25  ;    leather,  $5  00.  ' 

HEATH  (CHRISTOPHER).    PRACTICAL  ANATOMY  ;  A  MANUAL 
OF  DISSECTIONS.     With  additions  by  W.  W.  Keen    M  ^  "^ 

IJERMANN   (L)     EXPERIMENTAL  PHARMACOLOGY.      A  Hand- 
■LL    book  of  the  Methods  for  Determining  the  Physiological   Actions  of 

Drugs.    Trarslated  by  Rot  ert  Meade  Smith.  M'.D.    In  one  12mo  vol 

of  199  pages,  with  32  illustrations.  Cloth,  81  50.  (J„sl  ready  ,  ' 
mLL  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS  DIS- 
•*~^  ORDERS  In  one  8vo.  volumeof  479  pages.  Cloth,  $3  25. 
ITILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.  2d  ed. 
•*-*■  In  oneroyal  12mo.  voIumeof353pp..  with  twoplates.  Cloth  $225 
IJOBLYN  (RICHARD  D.)  A  DICTIONARY  OF  THE  TERMs'uSED 
-LL   IN   MEDICINE  AND  THE  COLLATERAL   SCIENCES.     In  one 

i2mo.  vol.  of  520  double-columned  pp.  Cloth,  $1  50  ;  leather,  $2. 
IJODGE  (HUGH  L.)  ON  DISEASES  PECULIAR  TO  WOMEN  IN-' 
■LL    CLUDING  DISPLACEMENTS  OF  THE  UTERUS.     Second  and 

revised  edition.     In  one  Svo.  volume  of  519  pages.     Cloth    S4  50 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS'.   In  one 


large  4to.  vol.  of  542  double-columned  pages,  illustrated  with  large 

lithographic  plates  containing  159  figures  from  original  photographs 
and  110  woodcuts.     Strongly  bound  in  cloth,  $14.  ' 

ITOFFMANN    (FREDERICK)    AND    POWER    (FREDERICK   B  )      A 

•LL    MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the  Examina- 
tion of  Medicinal  Chemicals  and  their  Preparations.    Third  edition 
entirely  rewritten  and  much  enlarged.     In  one   handsome   octavo 
volume  of  621  pages,  with  179  illustrations.     Cloth,  $4  25.     {Jjut 
ready.) 

ITOLDEN  (LUTHER).    LANDMARKS,  MEDICAL  AND  SURGICAL. 

-*-*•    From  the  third  English  edition.     With  additions,  by  W.  W,  Keen 
M.D.     In  one  royal  ]2mo.  vol.  of  148  pp.     Cloth    $1 

IJOLLAND  (SIR  HENRY).  MEDICAL  NOTES  AND  REFLECTIONS. 

•LL    From  3d  English  ed.     In  one  8vo.  vol.  of  493  pp.     Cloth,  $3  50. 

TTOLMES  (TIMOTHY.)    A  SYSTEM  OF  SURGERY.    With  notes  and 

-'-'-    additionsby  various  American  authors.  Edited  by  John  H.  Packard 
M.D.     In  three  very  handsome  Svo.  vols,  containing  3137  double- 
columned  pages,   with  979  woodcuts   and  13   lithographic  plates. 
Cloth,  •jlS;  leather,  $21;  very  handsome  half  Russia,  raised  bands 
$22  50.      For  sale  by  subscript io7i  only. 

HOLMES  (TIMOTHY).  SURGERY,  ITS  PRINCIPLES  AND  PRAC- 
TICE. In  one  handsome  octavo  volume  of  968  pages,  with  411  illus- 
trations. Cloth,  $6;  leather,  raised  bands,  $7;  very  handsome 
half  Russia,  raised  bands,   $7  50. 

HORNER  (WILLIAM  E.)  SPECIAL  ANATOMY  AND  HISTOLOGY. 
Eighth  edition,  revised  and  modified.  In  two  large  Svo.  vols,  of  1007 
pages,  containing  320  woodcuts.     Cloth,  $6. 

HUDSON   (A.)      LECTURES   ON    THE    STUDY    OF   FEVER.      In 
one  octavo  volume  of  SOS  pages.     Cloth,  $2  50. 
HUGHES.     SCRIPTURE    GEOGRAPHY    AND    HISTORY^  with   12 
colored  maps.     In  one  12mo.  volume.     Cloth,  $1. 
HYDE  (JAMES  NEVINS).  A  PRACTICAL  TREATiSE  ON  DISEASES 
OF  THE  SKIN.     In  one  handsome  octavo  volume  of  570  pao-es, 
with  66  illust.     Cloth,  $4  25;   leather,  $5  25.      {Just  ready.) 
TONES  (C.  HANDFIELD).    CLINICAL  OBSERVATIONS  ON  FUNC- 
^       TIONAL  NERVOUS  DISORDERS.    Second  American  edition.    In 
one  octavo  volume  of  340  pages.     Cloth,  $3  25. 


8  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

KEATING  (JOHN  M.)     THE    CARE  OP  INFANTS.     In  one  small 
12mo.  volume  of  118  pages.     Cloth,  $1. 
KING   (A.  F.   A.).      A  MANUAL  OF  OBSTETRICS.      In  one  very 
handsome  12mo.  vol.  of  321  pajices,  with  58  illustrations.    Cloth.  $2. 
KLEIN   (E  )     ELEMENTS    OF   HISTOLOGY.     See   Students''   Seiies 
of  Manufils,  pacfe  11. 
LA  ROCHE  (R  )    YELLO\Y  FEVER.    In  two  8vo.  vols,  of  1468  pages. 
Cloth,  $7. 

PNEUMONIA.    In  one  8vo.  vol.  of  490  pages.     Cloth,  $.3. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C.)  A  HANDY-BOOK 
OF  OPHTHALMIC  SURGERY.  Second  edition,  revi.^ed  by  Mr. 
Laurence.     In  one  8vo.  vol    pp.  227.  with  66  illus.     Cloth,  $2  75. 

LAWSON  (GEORGE) .  INJURIES  OF  THE  EYE,  ORBIT  AND  EYE- 
LIDS. From  the  last  English  edition.  In  one  handsome  octavo 
volume  of  404  pajres,  with  92   illustrations.     Cloth,  $.3  50. 

LEA  ( HENRY  C.)  SUPERSTITION  AND  FORCE  .  ESSAYS  ON  THE 
WAGER  OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL 
AND  TORTURE.  Third  edition,  thoroughly  revised  and  greatly 
enlarged.    In  one  handsome  roval  1  2rao.  vol.  pp  552.    Cloth.  $2  50. 

STUDIES  IN  CHURCH  HISTORY.     The  Rise  of  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.     New  edition.     In 
one  handsome  12mo.  vol.  of  605  pp.     Cloth,  $2  50.     {Just  ready) 

AN   HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


IN  THE  CHRISTIAN  CHURCH.    In  one  handsome  octavo  volume 
of  602  pages.     Cloth,  $2  50. 
T  EEfHENRY)  ON  SYPHILIS.  Inone8vo. vol.  pp  246.   Cloth, $2  25. 

TEHMANN  (C.  G.)     A  MANUAL   OF   CHEMICAL  PHYSIOLOGY. 

-LJ     In  one  8vo.  vol.  of  327  pages,  with  41  woodcuts.    Cloth,  $2  25. 

TEISHMAN   (WILLIAM).     A  SYSTEM  OF  MIDWIFERY.     Includ- 

-Ll  ing  the  Diseases  of  Pregnancy  and  the  Puerperal  State.  Third 
American,  from  the  third  English  edition.  With  additions,  by 
J.  S.  Parry,  M.D.  In  one  very  handsome  octavo  volume  of  740 
pages,  with  205  illustrations.  Cloth,  $4  50;  leather,  $5  50;  very 
handsome  half  Russia,  $6. 

LUDLOW  (J.  L.)  A  MANUAL  OF  EXAMINATIONS  UPON  ANA- 
TOMY.  PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE, 
OBSTETRICS,  MATERIA  xMEDICA,  CHExMISTRY,  PHARMACY 
AND  THERAPEUTICS.  To  which  is  added  a  Medical  Formulary. 
Third  edition.  In  one  royal  12mo.  volume  of  816  pages,  with  370 
woodcuts.     Cloth,  $3  25;   leather,   $3  75. 

LYNCH  (W.  F.)     A  NARRATIVE  OF  THE  UNITED  STATES  EX- 
PEDITION TO  THE  DEAD  SEA  AND  RIVER  JORDAN.     In  one 
large  octavo  vol.,  with  28  beautiful  plates  and  two  maps.  Cloth,  $3. 
. Same  Work,  condensed  edition.   One  vol.  roval  I2mo.    Cloth,  $1. 

LYONS  (ROBERT  D.)  A  TREATISE  ON  FEVER.  In  one  octavo 
volume  of  362  pages.     Cloth,  $2  25. 

MACFARLANE'S  TURKEY  AND  ITS  DESTINY.     In  2  vols,  royal 
12mo.     Cloth,  $2. 
MAISCH  (JOHN  M.)     A  MANUAL  OF  ORG\NIC  MATERIA  MED- 
ICA.    In  one  handsome  l2mo.  volume  of  461  pages,  with  194  beauti- 
ful illustrations.     Cluth.  $2  75. 

MARSH  (MRS.)    A  HISTORY  OF  THE  PROTESTANT  REFORMA- 
TION IN  FRANCE.     In  2  vols,  royal  12mo.     Cloth,  $2. 
MEIGS  (CHAS.  D.)    ON  THE  NATURE,  SIGNS  AND  TREATMENT 
OF  CHILDBED  FEVER.    In  one  8vo.  vol.  of  346  pages.    Cloth,  $2. 

MILLER  (JAMES).  PRINCIPLES  OF  SURGERY.  Fourth  American, 
from  the  third  Edinburgh  edition.  In  one  large  octavo  volume  of 
688  pages,  with  240  illustrations.     Cloth,  $3  75. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  9 


MIILER  (JAMES).  THE  PRACTTCE  OF  SURGERY.  Fourth 
American,  from  the  hist  Edinburgh  edition.  In  one  large  octavo 
volume  of  C82  pjiges,  with  .SR4  illu.strations.     Cloth,  $3  75. 

MITCHELL   rS.  WEIE).     LECTURES    ON   NERVOUS    DLSEASBLS, 
ESPECIALLY  IN  WOMEN.     Second  edition.      (Prpparing.) 
MONTGOMERY  (W.  F.)      AN  EXPOSITION  OF  THE  SIGNS  AND 
SYMPTOMS  OF  PREGNANCY.    From  the  .second  English  edition. 
In  one  handsome  8vo.  vol.  of  568  page.«i,  with  illus.     Cloth,  %?,  75. 

TWrOERIS   (MALCOLM).     SKIN  DISEASES:   Including  their  Defini- 
■"'-'■  tions,    Symptoms,   Diagnosis.  Prognosis,    Morbid    Anatomy    and 

Treatment.     A    Manual  for  Students  and   Practitioners      In  one 

12mo.  vol.  of  316  pages,  with  illustrations.     Cloth,  $1  75. 
TWrULLER  (J.)     PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY. 
-"J-   In  one  large  Svo.  vol.  of  623  pnges,  with  538  cuts.     Cloth,  $4  50. 
'M'EILL  (JOHN)  AND  SMITH  (FRANCIS  G.)     A  COMPENDIUM  OF 
^    THE  VARIOUS  BRANCHES  OF   MEDICAL  SCIENCE.    In  one 

handsome  12mo.  volume  of  974  pages,  with  374  woodcuts.     Cloth, 

$4  ;  leather,  raised  bands,  §4  75. 

NETTLESHIP'S  MANUAL  OF  OPHTHALMIC  MEDICINE  Second 
edition.  In  one  royal  12mo.  volume  of  419  pages,  with  138  illus- 
trations.    Cloth,  $2  00.      {Just  ready.) 

PAGET'S  HUNGARY  AND  TRANSYLVANIA.    In  two  royal  12mo. 
volumes.     Cloth,  $2. 
pARRISH  (EDWARD).    A  TREATISE  ON  PHARMACY.    With  many 
J-      Formulae  and  Prescriptions.  Fifth  edition,  enlarged  and  thoroughly 
revised  by  Thomas  S.  Wiegand,  Ph.  G.     In  one  handsome  octavo 
volume  of  about  J 000   pages,  with   about  300  illustrations.     (In 
press.) 
pARVlN  (THEOPHILUS).    A  TREATISE  ON  MIDWIFERY.    In  one 
-*■       handsome  8vo.  vol.  of  about  550  pp. ,  with  many  illus.      (In  press.) 

PAVY  (F.  W.)    A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION, 
ITS  DISORDERS  AND  THEIR  TREATMENT.    From  the  second 
London  edition.     In  one  octavo  volume  of  238  pages.     Cloth,  $2. 
pEPPEK  (A.J)     SURGICAL    PATHOLOGY.     See  St2ide7its'  Series 
•^      (9/"  M««?/c/5,  page  11. 

piRRIE  (WILLIAM).  THE  PRINCIPLES  AND  PRACTICE  OF  SUR- 
-•-      GERY.    In  one  handsome  octavo  volume  of  780  pages,  with  316 
illu.stration8.     Cloth,. $3  75. 

PIAYFAIR  (W.  S.)  A  TREATISE  ON  THE  SCIENCE  AND  PRAC- 
TICE OF  MIDWIFERY.  Third  American  edition,  .specially  revised 
by  the  Author.  Edited,  with  additions,  by  R.  P.  Harris,  M.D. 
In  one  octavo  volume  of  659  pages,  with  183  woodcuts  and  two 
plates.     Cloth,  $4;  leather,  $5;   half  Russia,  raised  bands,  $5  50. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE    PROSTRA- 

TION  AND  HYSTERIA.    In  one  handsome  ]2mo.  voL  of  97  pages. 
Cloth,  $1.      {Just  ready  ) 

POLllZER  (ADAM).  A  TEXT-BOOK  OF  THE  EAR  AND  ITS  DIS- 
EASES. Translated  at  the  Author's  request  by  James  Patterson 
Cassells,  M.D,  F  F.P.S.  In  one  handsome  octavo  volume  of  800 
pages,  with  257  original  illustrations.     Cloth,  $5  50.    {Just  ready.) 

pOWER  (HENRY).     HUMAN  PHYSIOLOGY.     Se&  Students' Series 
■^      of  Manuals,  page  11. 

PULSZKY'S  MEMOIRS  OF  AN  HUNGARIAN  LADY.    In  one  royal 
12mo.vol.     Cloth,  $1. 
pALFE    (CHARLES    H.)      PATHOLOGICAL    CHEMISTRY.       See 
J-u     Stiidmts''  Series  of  Manuals,  page  11. 

RAMSBOTHAM  (FRANCIS  H.)  THE  PRINCIPLES  AND  PRAC- 
TICE OF  OBSTETRIC  MEDICINE  ANDSURGERY.  Inoneira- 
perial  octavo  volume  of  640  pages,  with  64  plates,  besides  numerous 
woodcuts  in  the  text.     Strongly  bound  in  leather,  $7. 


10  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

•pEMSEN(IRA).  THE  PRINCIPLES  OF  CHEMISTRY.    Second  edi- 

-*-*'     tion.    In  one  handsome  12mo.  volume  of  about  250  pp.  {Preparing.) 

"DEYNOLDS  (J.  RUSSELL)      A  SYSTEM  OF  MEDICINE, with  Notes 

J-**     and  Additions,  by  Henry  Hartshorne.  M.D.    In  three  large  8vo. 

vols.,  containing  3056  closely  printed  double-columned  pages,  with 

317  illus.     Per  vol.,  cloth,   $5;  leather,  $6;    very  handsome  half 

Russia,  $6  50.      For  sale  by  subscription  oiily. 

-piCHARDSON  (BENJAMIN  W)     PREVENTIVE  MEDICINE.    In 
-L^     one  octavo  volume  of  about  500  pages.     {In  press.) 

"pOBERTS  (JOHN  B.)     THE    PRINCIPLES    AND    PRACTICE    OF 
J-*'    SURGERY.     In  one  octavo  volume  of  about  500  pages,  fully  illus- 
trated.     {Preparing-.) 
ROBERTS  (WILLIAM).   A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES.     Fourth  American,  from  the  fourth 
London  edition.    With  numerous  illustrations  and  a  colored  plate. 
In  one  very  handsome  8vo.  vol.  of  over  600  pages.      {Preparing.) 
OARGENT  (F.  W.)     ON  BANDAGING  AND  OTHER  OPERATIONS 
^     OF  MINOR  SURGERY.     New  edition,  with  an  additional  chapter 
on  Military  Surgery.    In  one  handsome  royal  12mo.  volume  of  383 
pages,  with  187  woodcuts.     Cloth,  SI  75. 

S CHAFER  (EDWARD  ALBERT).  A  COURSE  OF  PRACTICAL  HIS- 
TOLOGY :  A  Manual  of  the  Microscope  for  Medical  Students.  In 
one  handsome  octavo  volume,  with  many  illustrations.    Cloth,  $2. 

SCHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES.  In  royal  18mo. 
ADVANCED  LATIN  EXERCISES,  WITH  SELECTIONS  FOR 
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C.  C.  SALLUSTII  DE  BELLO  CATILINARIO  ET  JUGURTHINO. 
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CORNELII  NEPOTIS  LIBER  DE  EXCELLENTIBUS  DUCIBUS 
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P.  VIRGILII  MARONIS  CARMINA  OMNIA.     Price  in  cloth,  85 

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SCHOEDLER  (FREDERICK)  AND  ittEOLOCK  (HENRY) .  WONDERS 
OF  NATURE.  An  elementary  introduction  to  the  Sciences  of 
Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany,  Zool- 
ogy and  Physiology.  Translated  from  the  German  by  H.  Medlock. 
In  one  8vo.  vol.,  with  679  illustrations.     Cloth,  §3. 

S FILER  (CARL)  A  HANDBOOK  OF  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  THROAT  AND  NASAL  CAV- 
ITIES. Second  edition.  In  one  very  handsome  12iuo.  volume  of 
294  pages,  with  77  illustrations.     Cloth,  $1  75.      {Just  ready.) 

SHARPEY  (WILLIAM)  AND  QUAIN  (JONES  AND  RICHARD). 
HUMAN  ANATOMY.  With  notes  and  additions  by  Jos.  Leidy, 
M.  D.,  Prof,  of  Anatomy  in  the  University  of  Pennsylvania.  In  two 
large  8vo.  vols,  of  about  1300  pages,  with  51  1  illustrations. 

S KEY  (FREDERIC  C.)     OPERATIVE  SURGERY.    In  one  8vo.  vol. 
of  over  650  pages,  with  81  woodcuts.     Cloth,  $3  25. 
SLADE(D.D.)    DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 
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OMALL  BOOKS  ON  GREAT  SUBJECTS.     In  3  vols.     Cloth,  $1  50. 

SMITH   (EDWARD).    CONSUMPTION;   ITS  EARLY  AND  REME- 
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SMITH  (EUSTACE) .  ON  THE  WASTING  DISEASES  OF  CHILDREN. 
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HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  11 

SMITH  (HENRY  H.)  AND  HORNER  (WILLIAM  E.)  ANATOMICAL 
ATLAS.  Illustrative  of  the  structure  of  the  Ilumnn  Botly.  In  one 
large  imperial  8vo.  vol . .  with  ahout  fi.OO  l)eautiful  fijjurep.  Clo.,  $4  50. 

SMITH  (J.  LEWIS).  A  THEATISE  ON  THE  DISEASES  OF  IN- 
FANCY  AND  CHILDHOOD.  Fifth  edition,  revi.sed  and  enlarged. 
In  one  large  Svo.  volume  of  SS*^  page.s,  with  illustration-s.  Cloth, 
$4  50  ;  leather,  $5  50  ;  very  handsome  half  Russia,  raised  bands,  $6. 

STILLE  (ALFRED).  THERAPEUTICS  AND  MATERIA  MEDIC  A. 
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STILLE  (ALFRED)  AND  MAISCH  (JOHN  M  )  THE  NATIONAL 
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Pharmacy.  Actions,  and  Uses  of  Medicines.  Including  those  re- 
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Third  edition,  thoroughly  revised  and  greatly  enlarged.  In  one 
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ral hundred  accurate  engravings  on  wood.  (  hi  press.) 
STIMSON  (LEWIS  A.)  A  PRACTICAL  TREATISE  ON  FRAC- 
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A  MANUAL  OF  OPERATIVE  SURGERY.    In  one  royal  12mo. 

volume  of  477  pages,  with  332  illustrations.     Cloth,  $2  50. 
qTOKES(W.)    LECTURES  ON  FEVER.    In  one  Svo.  vol.   Cloth,  $2. 

STRICKLAND  (AGNES).  LIVES  OF  THE  QUEENS  OF  HENRY 
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$1  40  ;   black  cloth,  $1  30. 

STUDENTS'  SEKIES  OF  MANUALS.  A  series  of  fifteen  Manuals  by 
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TANNER  (THOMAS  HAWKES).  A  MANUAL  OF  CLINICAL  MEDI- 
CINE  AND  PHYSICAL  DIAGNOSIS.  Third  American  from  the 
second  revised  English  edition.  Edited  by  Tilbury  Fox,  M.  D.  In 
one  handsome  ]2mo.  volume  of  362  pp.,  with  ill  us.     Cloth,  $1  50. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    From 

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TAKNIER  (S.)  and  CHANTRHUIL  (G.)  A  TREATISE  ON  THE 
ART  OF  OBSTETRICS.  Translated  from  the  French.  In  two 
large  octavo  volumes,  richly  iliuftrated. 

TAYLOR  (ALFRED  b.)  MEDICAL  JURISPRUDENCE.  Eighth 
American  from  tenth  Engiitsh  e<lition,  specially  revised  by  the 
Author.  Edited  by  John  J.  Reese,  M.D.  In  one  large  octavo 
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UN  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDICAL 

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12         HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

THOMAS  (T.  GAILLARD).  A  PRACTICAL  TREATISE  ON  THE 
DISEASES  OF  WOMEN.  Fifth  edition,  thoroughly  revised  and 
rewritten.  In  onelargeand  handsome  octavo  volume  of  810  page.«, 
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Russia,  $6  50. 

THOMPSON  (SIR  HENRY) .  CLINICAL  LECTURES  ON  DISEASES 
OF  THE  URINARY  ORGANS.  Second  and  revised  edition.  In 
one  octavo  volume  of  203  pages,  with  illustrations.     Cloth,  $2  25. 

THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULA.  From  the  third 
English  edition.  In  one  octavo  volume  of  359  pages,  with  illus- 
trations.    Cloth,  $3  50. 

TIDY    (CHARLES    MEYMOTT).     LEGAL    MEDICINE.      Volume  I. 
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ACUTE  DISEASES.    In  oneSvo.  vol.  of  320  pp.,  cloth,  $2  50. 
•TREVES    (F.)       APPLIED    ANATOMY.      See    Snidtnts''    Series   of 
-'•     Majiiials,  page  11. 

rpUKE  (DANIEL  HACK).   THE  INFLUENCE  OF  THE  MIND  UPON 
•*-      THE  BODY.   New  edition.    In  onehandsome  8vo.  vol.  (PAe^^ari^/g^.) 

WALSHE  (W.  H.)  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  THE  HEART  AND  GREAT  VESSELS.  3d  American  from  the 
3d  revised  London  edition.   In  one  Svo.  vol.  of420  pages.   Cloth,  $3. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and  en- 
larged English  edition,  with  additions  by  H.  Hartshorne,  M.D.  In 
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WELLS  (J.  SOELBERG)  A  TREATISE  ON  THE  DISEASES  OF 
THE  EYE.  Fourth  edition,  thoroughly  revised  by  Chas.  S.  Bull, 
A.M.,  M.D.  In  one  large  and  handsome  octavo  vol.  of  822  pages, 
with  6  colored  plates  and  257  woodcuts,  as  well  as  selections  from 
the  test-types  of  Jaeger  and  Snellen.  Cloth,  $5;  leather,  $6;  very 
handsome  half  Russia,  $6  50.      {Just  ready.) 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  third  English  edition.  In 
one  octavo  volume  of  543  pages.     Cloth,  $3  75  ;  leather,  $4  75. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILD- 

HOOD.  Fifth  American  from  the  sixth  revised  English  edition.  In 
one  large  Svo.  vol.  of  686  pages.     Cloth,  $4  50  ;  leather,  $5  50. 

ON  SOME  DISORDERS   OF    THE    NERVOUS  SYSTEM    IN 

CHILDHOOD.  From  the  London  edition.  In  one  small  12mo. 
volume  of  127  pages.     Cloth,  $1. 

ILLIAMS  (CHARLES  J.  B  ana  C.  T.)  PULMONARY  CONSUMP- 
TION :  ITS  NATURE,  VARIETIES  AND  TREATMENT.  In 
one  octavo  volume  of  303  pages.     Cloth,  $2  50. 

ILSON  (ERASMUS).     A  SYSTEM  OF  HUMAN  ANATOMY.     A 

new  and  revised  American  from  the  last  English  edition.   Illustrated 

with  397  engravings  on  wood.     In  one  handsome  octavo  volume 

of  6  16  pages.     Cloth,  $4  ;  leather,  $5. 
—  THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.     In 

one  handsome  royal  12mo.  vol.     Cloth,  $3  50. 

INOKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 

With  additions  by  the  Author.    Translated  by  James  R.  Chadwick, 

A.M.,  M.D.  In  one  handsome  8vo.  vol.  of  484  pages.  Cloth,  $4. 
OHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.     Translated 

from  the  8th  German  edition,  by  Ira  Remsen,  M.D.    In  one  12mo. 

volume  of  550  pages.     Cloth,  $3  00. 

OODBUKY   (FRAX^K),     A    HANDBOOK  OF    THE    PRINCIPLES 

AND  PRACTICE  OF  MEDICINE.       In  one  royal   12mo.  volume. 

(rrepa)i//g.) 


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